3 Types of Medical Records Important for Disability Claims Processing

by | Published on May 31, 2021 | Medical Record Review

Disability insurance is a great financial support for people who are unable to work due to a disabling injury or medical condition. People may opt for an individual disability income insurance (IDI) or a group long-term disability (LTD) insurance policy or social security disability insurance (SSDI). When people apply for disability insurance, health insurers or health plans need to review the claim forms and the entire medical chart. To make this review process easier, insurers and the attorneys supporting them utilize medical records services. The treating doctors’ notes compiled during the course of treatment are important medical evidence that the health insurer will be looking for. That is why a complete medical chart documenting all symptoms and clinical findings is so significant.

Medical chart reviews for claims processing purposes verify the medical information and also identifies whether any information has been omitted on the application. Let us look at the types of medical records that are important with regard to a disability claim.

  • Chart Notes: These comprise the information regarding the patient/applicant’s complaints, symptoms, medications prescribed, and the difficulty he/she experiences due to the disability. Looking at these, the insurer can determine when the disabling condition actually began and the diagnosis. By comparing the chart notes with the disability application, the disability insurer can find out whether or not the date of disability in the application is consistent with the chart notes. Chart notes are important also because disability carriers will first determine whether or not they should deny the claim based on the fact that the applicant’s condition is a preexisting condition that is excluded by the terms of the particular disability plan. They would look whether the applicant has/has not received treatment for the disabling condition during the pre-existing exclusionary period. If yes, the chart notes will be used to deny the claim.
  • Narrative Notes: These are the more detailed notes written by the treating physician and include information about the applicant’s appearance; any changes since his or her last appointment; changes in medications, if any; findings of medical exams; the doctor’s comments about the disability claimant’s diagnosis and prognosis. Narrative documentation helps understand whether the claimant’s condition has worsened over a period of time. The insurer will be looking for notes that accurately describe the claimant’s complaints, difficulties in functioning, and any changes he/she experienced between consultations.
  • Residual Functional Capacity Forms: These forms will provide details regarding the functional capacity of the disability applicant. They will show how much the claimant can lift, how often, how far, whether he/she needs to sit or lie down frequently, and whether he/she is likely to miss work. The treating doctor should fill out these forms circling the correct response and also provide notes clarifying their responses.

Disability insurers conduct medical record review periodically to find if there are any changes that show that the claimant is no longer disabled. They may contact the treating doctor for additional information occasionally during the time that the claimant remains out of work. Apart from this, they may also request additional information from the claimant. Examination records, test results, and the treating physician’s ongoing evaluation and diagnosis of the objective medical evidence are highly significant at each stage of the process.

Payers and disability attorneys supporting them partner with experienced medical review companies to get the relevant records and review them quickly. This also ensures that the records reviewed are complete and comprehensive and the required medical evidence is extracted. This in turn enables insurers to make a fair decision regarding the claim presented by the disability applicant. Accurate review of the disability claimant’s medical chart is significant not only from the point of view of making a fair disability decision, but also to prevent insurance fraud and consequent healthcare costs.

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