دليل المزود

مراجعات سجل العلاج

Providers are expected to cooperate with treatment record reviews conducted by Carelon as part of health plan operations. These reviews may occur:

• استجابة لقضية جودة معينة أو قلق ينشأ.
• للوفاء بمتطلبات وكالة الاعتماد أو الحساب التي تفرض المراجعة على أساس دوري أو عند الطلب.

Carelon will gain access to treatment records by reviewing them at the provider’s office or by asking the provider to photocopy and send the records. Prior to treating a member, the provider should obtain the member’s written consent to share their treatment information and records with Carelon. Providers must supply copies of requested records to Carelon within five (5) business days. Carelon will treat provider records confidentially as per all applicable Federal and State regulations.

Providers and vendors must, at their own expense, make all records available for audit, review or evaluation by Carelon. Access shall be provided by the provider either on-site, during regular business hours, or through the mail. During the contract and record retention periods, these records shall be available at a specific location. All mailed records shall be sent to Carelon in the form of accurate, legible, paper copies, unless otherwise indicated, within requested time frame.

Following the treatment record review, providers will receive a written report that details the findings. Included in the report will be an Action Plan with specific recommendations that will enable the provider to more fully comply with Carelon’s standards for treatment records.

Treatment records are reviewed through application of an objective instrument. The instrument is continuously under study and revision and Carelon reserves the right to alter it as needed.

For the purpose of conducting retrospective case review, clinical files pertaining to Carelon members should be maintained for six (6) years.

Carelon network providers are required to document service accessibility for the services that are provided. يجب أن يوفر مزود الشبكة التدخلات وجهًا لوجه في غضون ساعة واحدة لحالات الطوارئ ، وفي غضون 24 ساعة للحالات العاجلة ، وفي غضون سبعة أيام للمواعيد الروتينية والإحالات المتخصصة. Carelon collects and analyzes this data to measure performance against these contract standards. As part of a routine treatment record review, Carelon will audit for the following quality management criteria:

• تاريخ دعوة العضو الأولية لتحديد موعد ،
• نوع الموعد ، مثل الطوارئ أو العاجلة أو الروتينية ،
• تاريخ الموعد الأول المعروض ،
• تاريخ ووقت موعد التقييم الفعلي ، و
• توثيق سبب عدم استيفاء المعيار ، إن أمكن.

يتم نشر الإرشادات التشخيصية ومؤشرات الالتزام التشخيصي للاكتئاب الشديد والاضطراب ثنائي القطب والفصام واضطراب نقص الانتباه وفرط النشاط والاضطرابات العقلية والاضطرابات المرتبطة بالمواد على موقعنا للرجوع إليها على صفحة معلومات الموفر تحت قسم إدارة الجودة.