January 1, 2022 at 6:00 AM CT

Applicable to all states except NC.

Medical records standards and requirements - Chapter 12, 2021 UnitedHealthcare Administrative Guide

Access to records

Unless otherwise stated in your Agreement, you are required to:

  • Send copies of our members’ medical, financial, administrative, or purchasing and leasing records.
  • Supply records within 14 calendar days, free of charge.
    • Supply records faster in certain circumstances.
  • Maintain and protect records for 10 years.
  • Give access to records for all dates of service that occurred when you were a contracted provider.
  • Assist us, or our designee, in completing chart reviews for MA members.

Medical record standards

Access medical record tools, templates and patient safety resources on

Member encounters

For every visit, document the:

  • Member’s complaint or reason for the visit.
  • Physical assessment.
  • Unresolved problems from previous visit.
  • Diagnosis and treatment plans.
  • Member education, counseling or coordination of care with other care providers.
  • Date of return visit or other follow-up care, including phone calls.
  • Review by the primary care provider (initialed) on consultation, lab, imaging, special studies, and ancillary, outpatient and inpatient records.
  • Follow-up care plans.

When coding the encounter, pick the Evaluation and Management level from the member’s condition at the time of the visit.

Monitoring the quality of medical care through review of medical records

A well-documented medical record reflects the quality of care delivered to patients. Accreditation and regulatory groups review medical records as part of their oversight activities. Maintain your medical records in a manner that is current, detailed and organized. This allows for effective and confidential patient care and quality reviews.

Correspondence from the Quality of Care Department is considered privileged and confidential. You may not share the information with the patient or member. The involved care provider cannot discuss it with the member or any member representative. You may not file the communication in the patient’s medical record.

Medical records duplication

Medical Record Copies for Specialist Referrals — The PCP office pays for the cost of duplicating and shipping the records due to a referral. You cannot charge the member for records used during the member’s course of treatment.

Member Transfer to Another PCP — Do not charge the member if they need records sent to another PCP.

Member Request for Medical Records — The member, or member’s representative, may request copies of records from your office. You can charge a fee of up to 25 cents per page plus any reasonable clerical costs incurred, unless state laws indicates otherwise.

Medical record guidelines

Medical records must have all information necessary to support claims for your services. You are expected to have written policies for the following:

  • Medical records guidelines including maintenance of a single, permanent medical record that is legible, current and detailed.
  • Process for handling missed appointments.
  • Non-discrimination of health care delivery.
  • Staff training on confidentiality and safe record keeping.
  • Release of information.
  • Medical record retention.
  • Availability of medical records if housed in a different location.
  • Coordination of care between medical and behavioral care providers.
  • Process for notifying UnitedHealthcare upon becoming aware of a patient safety issue or concern.

General documentation guidelines

We expect you to follow guidelines for medical record information and documentation including the following:

  • Date all entries and identify the author and their credentials. It should be apparent from the documentation which individual performed a given service.
  • Clearly label or document changes to a medical record entry by including the author and date of change. You must keep a copy of the original entry.
  • Generate documentation at the time of service or shortly thereafter. Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the current record.
  • Include demographic information including name, gender, date of birth, member number, emergency contact name, relationship, phone number(s), and insurance information.
  • Include family and social history, including marital status and occupational status or history.
  • Prominently place information on whether the member has executed an advance directive. This is critical.
  • Include a problem list with medical history, chronic conditions and significant illnesses, accidents and operation. Include the chief complaint and diagnosis and treatment plan at each visit.
  • List medication allergies and adverse reactions. Also, note if the member has no known allergies or adverse reaction. This is critical.
  • Include name of current medications, dosages, and over-the-counter drugs.
  • Reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the care provider.
  • Document member history and health behaviors such as:
    • Tobacco habits, including advice to quit, alcohol use and substance use (age 11 and older).
    • Immunization record.
    • Preventive screenings/services and risk screenings.
    • Screenings for depression and evidence of coordination with behavioral care providers.
    • Blood pressure, height and weight, body mass index.
    • Physical assessment for each visit.
    • Growth charts for children and developmental assessments.
    • Physical activity and nutritional counseling.
  • Clinical decision and safety support tools in place to help ensure evidence based care and follow up care. Examples include:
    • Lab, X-ray, consultation reports, behavioral health reports, ancillary care providers’ reports, facility records and outpatient records show care provider review by signature or initials.
    • Report from eye care specialist related to medical eye examinations.

Record accuracy goals

  • 90% of medical records will contain documentation of critical measures.
  • 80% of medical records will contain documentation of all other elements when those elements are included in quality improvement medical record assessments.
  • 100% of medical records will contain documentation of allergies and adverse reactions.

Chart assessments and failure to comply

We have the right to assess care provider records to determine the accuracy of ICD-10-CM and CPT coding. We notify you of the results. We may charge a penalty if you fail to submit the information.

CMS risk adjustment and medical records

Medical records are important for both CMS reimbursement for our members and to accurately calculate an annual patient risk score that represents the specific patient’s disease burden for the Department of Health and Human Services (DHHS). Every year, CMS and DHHS require information about the demographic and health of our members. Diagnoses do not carry forward to the following year and must be assessed and reported every year. Records must show all conditions evaluated during the visit. It is important to evaluate all chronic conditions at least annually. You should report the appropriate diagnosis code for all documented conditions that coexist at the time of the visit that require or affect care.

For accurate reporting on ICD-10-CM diagnosis codes, the medical record documentation must describe the member’s condition. This should include specific diagnosis, symptoms, problems, or reasons for the visit. You are responsible for making sure ICD-10-CM coding adheres to ethical standards. Member charts are subject to review. We may review the charts to identify chronic diseases not coded on claims. CMS conducts assessments to confirm that the Hierarchical Condition Categories (HCCs) triggered for payment, based on ICD-10-CM coding, are supported by chart documentation. CMS works through us to obtain these records for the MA program. The DHHS requests this data from us for the commercial risk adjustment data. Since it is our legal obligation to provide this information to the federal agencies, we also appreciate and require your cooperation with this as well.