プロバイダーマニュアル

治療記録レビュー

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

  • 特定の品質問題または懸念が生じた場合。
  • アカウントまたは認定機関の要件を満たすため、定期的または要求に応じてレビューを義務付けます。

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. ネットワーク プロバイダーは、緊急の場合は 1 時間以内、緊急の場合は 24 時間以内、通常の予約と専門家の紹介の場合は 7 日以内に、対面での介入を提供する必要があります。 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:

  • メンバーの最初のアポイントメントの電話の日付、
  • 緊急、緊急、定期などの予定の種類
  • 提供された最初の予定の日付、
  • 実際の評価予約の日時、および
  • 該当する場合、基準が満たされていない理由の文書。

大うつ病、双極性障害、統合失調症、注意欠陥多動性障害、併発する精神および物質関連障害の診断ガイドラインと診断アドヒアランス指標は、当社のウェブサイトに掲載されています。 プロバイダー情報ページ 品質管理セクションの下。