Manual del proveedor

REVISIONES DEL EXPEDIENTE DE TRATAMIENTO

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

• En respuesta a un problema de calidad específico o una inquietud que surja.
• Para cumplir con los requisitos de las agencias de acreditación o cuentas que exigen una revisión periódica o previa solicitud.

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. Un proveedor de la red debe brindar intervenciones en persona dentro de una hora para emergencias, dentro de las 24 horas para situaciones urgentes y dentro de los siete días para citas de rutina y referencias especializadas. 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:

• La fecha de la llamada inicial del miembro para una cita,
• El tipo de cita, como emergencia, urgente o de rutina,
• La fecha de la primera cita ofrecida,
• La fecha y hora de la cita de evaluación real, y
• La documentación de la razón por la que no se cumplió la norma, si corresponde.

Las pautas de diagnóstico y los indicadores de adherencia al diagnóstico para la depresión mayor, el trastorno bipolar, la esquizofrenia, el trastorno por déficit de atención con hiperactividad y los trastornos mentales y relacionados con sustancias concurrentes se publican en nuestro sitio web como referencia en el Página de información del proveedor en la sección Gestión de la calidad.