Medical Record Denial and HIPAA Act 1996

What is Medical Record Denial in medical billing?

Medical Record Denial – Medical records are a written form of description of the treatment. For claiming insurance medical records are much needed. The provider should add the medical records with radiology reports, clinical notes, drugs, dosage, Observation records, and much more according to the treatment of the patient.

These written acknowledged records are called Medical records of a patient. Importantly, Medical records hold sensitive information of the patient. Utilizing them against the patient may lead to severe punishment per the HIPPA act.

HIPAA (Health insurance portability and Accountability Act of 1996)

The important motive of this HIPAA Act is to prevent releasing patients’ sensitive information. This was initiated by The US Department of Health and Human Services (HHS).

Without prior permission and consent from the patient. Accessing medical records and releasing them to others without their knowledge is a Crime.

Accessing patient’s medical records (Covered Entities)

Few are considered to access the medical records of the patient for the betterment of the patient called as Covered Entities. However, In groups, they are also subjected to the privacy rule.

  • Healthcare providers.
  • Health plans.
  • Healthcare clearinghouses.
  • Business associate.


Healthcare providers – Basically they are doctors treating the patient. They are allowed to access the medical records to treat the patient accordingly.

Health plans – They are called Insurance companies where the patient claims their medical expenses for reimbursement.

Healthcare Clearinghouse – This is basically a unit or database that owns all the information about the claims. This is basically a software database the claims are turned into ready reports.

Business Associates – They are medical billing companies that process the claim on behalf of the providers.

Electronic medical records

EMR is an electronic form of medical records replacing paper records. Instead of having multiple medical records patients have single electronic reports accessed everywhere.

According to a study published in the American journal of medicine say moving to electronic medical records minimized billing errors and expenditures.

Importantly, the Emr software provides links to videos, and articles, that can help the patient understand their current situation.


Disadvantages of Electronic medical records

  • Maintenance can cost up to $30,000 per provider.
  • Specific training for patients is required to access EMR.
  • Increased work to feed the reports and separate email system required.
  • Storing medical records in the cloud can lead to hackers utilizing it. Hence layer of security cost increases.

Electronic medical records companies

  1. Simple practice.
  2. Epic system.
  3. All scripts.
  4. Athena health.
  5. Nextgen Healthcare.
  6. Insta.
  7. E-Hospital system.
  8. Kareo clinical.

Electronic medical records software comparison

three best open source Emr 2021


Questionnaire for Medical Record Denial in medical billing.

If a claim is denied for need in medical records. Check for the software if you have medical records call the payor and send the claim back for reprocessing. Stating the medical records send along with the claim.

If, the rep is stating needs additional medical records from the provider. Get the requested medical records from the provider and resubmit the claim for payment.

Claim denied for need in medical records


In short, Medical records are much needed to process the claim. There can be two scenarios. One is you have to get the medical records from the provider end and send it to insurance if they ask for additional information. secondly, ask the rep to send the claim back for reprocessing if it already exists.


1 thought on “Medical Record Denial and HIPAA Act 1996”

Leave a Comment