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Timely Submission of Medicare Advantage HMO and PPO Members’ Medical Records

As part of the federally mandated Medicare Advantage Appeals and Grievances process, IBC is required to obtain a member’s medical record in order to make a determination of coverage. Should we uphold our determination, we are required to forward the member’s appeal file, which includes medical records, to an independent review entity (IRE). An IRE is contracted with the Centers for Medicare & Medicaid Services (CMS) to perform second-level independent reviews of Medicare Advantage members’ appeals. Medical records must be submitted to us in a timely manner.

To learn more about the medical records process and other reasons why you may be required to submit medical records, refer to the February edition of Partners in Health Update^SM.