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Wisdom Bites! Documenting and Denying a Claim with Information on File
Lemonade
Created on October 20, 2025
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Transcript
Wisdom Bites!Documenting and Denying a Claim with Information on File
October 2025
Denials With The Information on File
How to handle a known denial with limited information on file! Following these steps will help to avoid claims being paid out instantly for ineligible conditions and prevent policyholder dissatisfaction. Click on the +info below for more information!
+ info
MR Completeness Toggle
MR Incomplete
Click the +info below for a refresher!
Click the +info below for a refresher!
+ info
+ info
Claim Investigation Reminder
If in reviewing information on file prior to requesting medical records, it’s clear the current claim is a denial, it is okay to deny claim with information on file. Add the PEC to the PEC table and medical timeline and add the incomplete reason.
Claim Investigation Guru Card found here:
If you know a claim is a clear denial with what you have on file, deny it with no further information. This saves time for the policyholder and other departments (ex. MRR).
If You Can, Do it!
As Medical Record Advisor becomes more proficient, this will be a more common occurrence. So please make sure you're completing this when applicable.
MR Advisor
Even if the claim does not need a full MRR, it is the Advocates responsibility to mark the condition as PEC in the table and in the medical timeline, AND update the MR Completeness Toggle.
Documentation
Medical Record Completeness Toggle
To continue to train the model, indicate if records are complete OR select a reason why they’re not complete. This should be done any time the MR Completeness AI was performed.
Pet Medical History View
Do not mark the MRR as copleted if a complete MRR was not performed. Just make sure the PEC is in the PEC table and the medical timeline (not pictured)