Review of medical records usually fits within 30–45 days after all documents arrive, set by state claim-handling rules.
When claim handlers request treatment notes, bills, and test results, the clock usually starts once the insurer has everything it needs. From that point, many states give an insurer a set window to accept or deny a claim or explain why more time is needed. The exact window varies by state and claim type, but a common pattern is 30–45 days after receipt of complete proof of loss. The sections below break this down, show where the time comes from, and give steps you can take to keep things moving.
What Drives The Timeline
Three forces shape how long a reviewer takes with health documentation: state claim-handling rules, health-privacy rules that control how fast providers release records, and the insurer’s internal process. Each adds its own deadline or checkpoint. Combine them, and you’ll see why many files land in the 30–45 day band once the adjuster has a full packet.
Common Rules And Deadlines (At A Glance)
The table below maps frequent deadlines that affect a file with treatment documentation. These are examples from widely used rules and regulations. Actual limits depend on the policy and the state governing the claim.
| Rule Or Context | What It Controls | Typical Deadline |
|---|---|---|
| State claims-handling window (e.g., California) | Decision after insurer receives proof of claim | Up to 40 calendar days to accept/deny; written updates every 30 days |
| State prompt-payment window (e.g., Texas) | Decision after insurer has all requested items | 15 business days to accept/deny; may extend to 45 days with notice |
| Provider record release (HIPAA Right of Access) | How fast hospitals/clinics send records after a valid request | 30 days; one 30-day extension allowed with written notice |
| State claims-handling window (e.g., New York) | Decision after receiving proof of loss and all requested forms | 15 business days to accept/deny; longer in specified cases |
| Insurer internal review | Medical coding, liability analysis, supervisor sign-off | Varies by company; often fits inside state deadlines |
How Long Do Adjusters Take To Review Treatment Files?
Once the file is complete, many jurisdictions push the insurer toward a decision in about a month, give or take. Several states require a written acceptance or denial within a fixed period after proof of claim is in hand. California’s consumer rules, for example, set a 40-day cap to accept or reject after proof of claim, with written status letters every 30 days until the decision lands.
Other states key the deadline to “all items received.” Texas gives insurers 15 business days to decide once all requested records and forms are in the file, with the option to extend up to 45 days if the carrier sends a notice explaining why more time is needed.
New York’s claims rules take a similar approach: after a completed proof of loss and requested materials arrive, the insurer has 15 business days to advise in writing whether it accepts or rejects the claim, with special timing in certain situations.
Why Record Release Timing Matters
The adjuster’s review can’t start until providers send what was authorized. Health-privacy rules give clinics and hospitals up to 30 days to supply copies of treatment notes, bills, and images, with a single 30-day extension if they send a written delay notice. That release timeline is separate from any insurer deadline; it explains a large share of “waiting on records” delays.
If your file straddles multiple providers—ER visit, primary care follow-ups, imaging center, and PT—all those requests stack. A bottleneck with any one clinic can slow the packet that lands on the adjuster’s desk.
What “Complete Proof Of Claim” Usually Means
State rules tie decision-day clocks to the moment the carrier has a complete package. In a bodily injury context, that often includes:
- Signed authorization or provider invoices and notes.
- Diagnostic reports (X-ray, CT, MRI) and radiologist reads.
- Treatment plans, discharge summaries, and referral notes.
- Itemized bills with CPT/HCPCS codes and ICD injury codes.
- Wage verification and employer letters if lost income is claimed.
- Accident details, photos, and any police report number.
When any piece is missing, many states allow the carrier to pause the decision clock and request the specific item, then resume timing once it arrives. That’s why written requests from the adjuster should name the missing documents—so everyone knows what will restart the clock.
Typical Timeline Walkthrough
Here’s how a common sequence unfolds for an injury claim tied to treatment:
- Day 0–3: Claim notice goes in. The insurer acknowledges and opens a file.
- Day 3–10: The carrier requests medical records and bills from named providers.
- Day 10–40: Providers send records under health-privacy rules, often within 30 days; a clinic can request one 30-day extension with written notice.
- Day 30–45: Once the insurer has all items, state rules push a decision or prompt written updates if more time is needed—for example, 40 days in California or 15 business days in Texas (with a possible 45-day extension).
Authoritative Rules You Can Cite
Two widely referenced sources you can point to during a delay:
- HIPAA Right of Access explains a provider’s 30-day record-release window and the single 30-day extension limit.
- California Fair Claims Settlement Practices outline the 40-day decision rule and 30-day status letters after proof of claim.
State-By-State Variation
Claim-handling laws trace back to model rules from national insurance regulators, but each state writes its own version. The broad aim is prompt, fair investigation and timely decisions once liability is clear. Timing details differ, and some lines (property, auto, health, life) have their own sub-rules. If your claim is governed by a specific state, check that state’s code or administrative rules for the exact clock.
Medical Review Depth: What Adjusters Actually Read
Adjusters scan for causation, consistency, necessity, and cost reasonableness. A typical read includes triage notes, imaging, specialist consults, and PT progress notes. Coders may review CPT/HCPCS entries against physician notes. If gaps appear—missing diagnostics, unclear causation, or nonitemized charges—the carrier can ask for clarification, which pauses the path to a decision until the records arrive. Many state rules allow these written document requests and expect periodic status updates while the carrier waits.
Delays You Can Prevent
Some slowdowns are inside your control. You can:
- Use precise provider lists. Give complete facility names, dates of service, and medical record numbers if you have them.
- Supply itemized bills early. A summary balance rarely suffices for claims review.
- Check for imaging discs or links. Radiology reports and image access speed up reviews of soft-tissue claims.
- Flag pre-existing conditions up front. Clear charting reduces back-and-forth.
- Respond to document requests fast. Many states let carriers pause the decision clock while waiting for named items.
When A Review Crosses The Deadline
If the file passes the statutory window without a written decision or update, you can ask for a status letter that cites the rule in your state. California requires written updates every 30 days if a claim can’t be accepted or denied within 40 days. Texas requires notice when the carrier needs extra time and caps the extension at 45 days. New York calls for written acceptance or rejection within 15 business days after a complete proof of loss. These letters keep the clock transparent.
How Long Adjusters Wait For Providers
Health-privacy rules set the pace of record release at the source. Clinics have up to 30 days to fulfill a valid request, with one 30-day extension. If a facility uses the extension, the insurer can’t review what it doesn’t yet have. Asking providers to send records directly to you as well as the carrier can reveal bottlenecks early.
Proof-Of-Claim Milestones (Handy Reference)
Use this quick reference to track where you are in the process.
| Milestone | What To Expect | Practical Tip |
|---|---|---|
| Claim Opened | File number and acknowledgment | Confirm contact info and preferred channel |
| Records Requested | Provider release sent; waiting period starts | Ask each clinic for an ETA under the Right of Access |
| All Items Received | Decision clock begins under state rule | Note the date; track the state’s deadline window |
| Status Update Needed | Written letter if more time is required | Request the rule citation and next target date |
| Decision Issued | Acceptance with payment terms or written denial | Review the policy citation and appeal options |
Real-World Examples Of Timing Rules
California
Once proof of claim is complete, an insurer must accept or deny in no more than 40 calendar days. If more time is needed, the carrier sends a letter every 30 days explaining the status and any missing materials. This rule applies broadly to claims covered by the state’s consumer regulations.
Texas
After “all items, statements, and forms” are received, the insurer has 15 business days to accept or reject. If it needs more time, it must say why and can extend up to 45 days. When payment is owed, a separate prompt-payment clock applies.
New York
Within 15 business days after a completed proof of loss and all requested documents, the claimant must be advised in writing of acceptance or rejection, with specialized timing rules for certain scenarios.
How To Keep Your File On Track
Make The Record Requests Easy
Provide a clean list of providers with full addresses, dates of service, and medical record numbers if available. Attach signed HIPAA authorizations that name each facility. Ask providers to include itemized bills and diagnostic reports, not just balance statements.
Close Gaps Before They Become Delays
Cross-check visit dates in the bills against treatment notes. If the PT log ends mid-month or a radiology report is missing an addendum, request it right away. Small gaps trigger back-and-forth that stalls the decision clock.
Track The Clock In Writing
Note the date the insurer confirms receipt of all items. If the window passes without a decision, request a status letter and the next target date. When citing rules, you can point to your state’s code or an official consumer page like the California regulations or the HIPAA Right of Access guide linked above.
Key Takeaway
Most review periods sit in the 30–45 day range once the insurer has every record it requested. Delays before that point often come from provider release windows. The shortest path to a decision is simple: supply complete records fast, confirm when the file becomes “complete” under your state’s rule, and ask for written updates if a deadline passes.