Lack of Information (LOI) Retrospective Review - (UM-47)

This policy covers pended retrospective (post‑service) utilization reviews when reasonably necessary clinical information is missing and permits denial if required information is not provided, with customer/provider liability for denied claims determined by product and provider participation. Key requirements: send a "Pending Request for Additional Information" letter to provider and customer on day 0 and day 15, require records within 45 calendar days plus 5 mail days (decision process on/after day 51), allow one non‑urgent 15‑day extension, document the specific information requested and timelines in the UM system, have an MD review available clinical information (or outreach) and follow state‑specific timing (e.g., California).

"The purpose of this policy is to establish a consistent process for "pending" retrospective (i."

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