Medical records

Medical records are legal documents that detail a patient’s medical history, diagnoses, and treatments according to HIPAA (45 CFR §164.501). Insurance companies use medical records to verify claims data, such as dates of service and provided procedures.

Insurers request medical records during underwriting for life insurance policies exceeding $100,000 face value or when contesting disability claims. Health insurers review prescription lists and physician notes in medical records to detect undisclosed pre-existing conditions like diabetes or hypertension, as indicated by YourInsuranceInfo.

Under HIPAA, individuals may request copies of their own medical records from healthcare providers within 30 days (45 CFR §164.524). Errors in medical records, such as inaccurate allergy information or surgery dates, can result in delayed claim approvals or denials by insurers.

Medical coding within records (using ICD-10-CM codes) affects coverage decisions for procedures including joint replacements and cancer therapies. Electronic health record systems such as Epic and Cerner store the bulk of US medical records used in insurance reviews.

Life insurers retain requested medical records for up to seven years following a claim settlement per state regulations (e.g. California Insurance Code §10508).

Patients may redact mental health therapy notes from insurer-accessible medical record copies under federal law (45 CFR §164.524(a)(1)(i)). Insurers must obtain patient consent forms prior to directly accessing provider-maintained medical records during policy evaluations or disputes.