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January/February 2025 Top of Mind
Providers need to respond quickly to medical records requests for all lines of business
Optum may request medical records from you for multiple reasons including:
- Documentation of medical necessity to support a prior authorization request for treatment
- A clinical coverage review to validate that all services included in a claim are reflected in the patient’s file
- In response to a member’s request for an independent medical review
All record requests from Optum Behavioral Health will include a response due date – indicate the deadline for sending medical records – typically within 24, 48 or 72 hours – and outline the different methods available to submit the records.
Your contract (participation agreement) and the OptumHealth Behavioral Solutions of California Network Manual outline your responsibility to submit these records quickly. The network manual is considered a part of your participation agreement.
When a member asks for an independent medical review, California law outlines that both Optum and its providers must quickly provide the medical records needed.
The HIPAA Privacy Rule allows the release of protected health records to Optum, other health plans and business associates* when it’s related to the patient’s treatment, claim payment and health plan operations. If you have an annual signed HIPAA consent form from the patient, you’re all set. No additional consent is needed before you can respond to the individual record requests.
Avoid potential financial penalties
If medical records are not provided on time, Optum may have to pay penalties to government agencies like the Department of Managed Health Care. If this happens due to delays on your part, we have the right to recoup these financial penalties from you, as agreed to in your contract.
Questions?
Call the California customer service line: 1-800-999-9585.
*As outlined in HIPAA privacy regulations (45 CFR 160.103), Optum has entered into a business associate agreement with UnitedHealthcare. This means it can review claim information without additional patient authorization as a business associate for the purposes of enhancing member care.
BH00721-25-NEWS
