Manuale del fornitore

REVISIONI DEL RECORD DEL TRATTAMENTO

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

• In risposta a uno specifico problema di qualità o preoccupazione che si presenta.
• Per soddisfare i requisiti dell'account o dell'agenzia di accreditamento che richiedono una revisione periodica o su richiesta.

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 fornitore di rete deve fornire interventi faccia a faccia entro un'ora per le emergenze, entro 24 ore per situazioni urgenti ed entro sette giorni per appuntamenti di routine e referenze specialistiche. 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 data della prima chiamata del socio per un appuntamento,
• Il tipo di appuntamento, come emergenza, urgente o di routine,
• La data del primo appuntamento offerto,
• La data e l'ora dell'effettivo appuntamento per la valutazione e
• La documentazione del motivo per cui lo standard non è stato soddisfatto, se applicabile.

Le linee guida diagnostiche e gli indicatori di aderenza diagnostica per depressione maggiore, disturbo bipolare, schizofrenia, disturbo da deficit di attenzione e iperattività e disturbi mentali e correlati alle sostanze concomitanti sono pubblicati sul nostro sito Web per riferimento Pagina di informazioni del fornitore nella sezione Gestione della qualità.