The insurer says it is waiting for medical records my doctor already sent. How do I clear the hold?
A records-requested hold is an open item, not a denial, and it clears when the insurer's claims team attaches the records to the claim number. Get proof of the provider's transmission, ask the insurer in writing exactly which records it wants and where, send them yourself marked with the claim number, and ask for the claim to be decided within the plan's timeframe.
What to do, in order
- Step 1
Get proof of the first send
Ask the provider's office for the fax confirmation or portal receipt: date, time, number of pages, destination. That document is what turns "we never got them" into "you got them on this date".
- Step 2
Ask the insurer what, exactly, and where
In writing: the list of records requested, the date of the request, the address or fax number, and the claim number they will be attached to. Insurers often request records into a vendor or a general queue that does not talk to the claim.
- Step 3
Send them yourself, labelled
Send the records with a cover page carrying the claim number, member ID, date of service, and the sentence "in reply to your request of [date]". Keep the confirmation.
- Step 4
Start the clock
Ask for the claim to be decided within the plan's post-service timeframe from the date the records were received. If the plan does not decide, write that the request is complete and any further delay is a denial you are appealing.
The deadline that applies
ERISA plans must decide a post-service claim within 30 days, one 15-day extension if they tell you what is missing, and the member gets at least 45 days to supply it (29 CFR 2560.503-1(f)). Once the records are in, the clock resumes. ACA plans follow the same structure (45 CFR 147.136). The written notice controls.
Calculate your date →Documents to gather
- The insurer's records request (the EOB code or letter)
- The provider's transmission proof
- The records themselves with a labelled cover page
- Your written request for the claim to be decided, with the date
Go deeper
Related questions
Is a records hold a denial?
Not yet. It becomes one if the plan denies for lack of records or lets its timeframe run. Treat the timeframe as the deadline.
Can I send the records myself?
Yes. You are entitled to your records and the insurer must accept them from you with the claim number.
The insurer's vendor got the records but the claim still shows the hold. Why?
Vendor and claims systems are often separate. Send the records directly to the claims address with the claim number and ask for written confirmation they are attached.
Sources
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