제공자 매뉴얼

치료 기록 검토

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

  • 발생하는 특정 품질 문제 또는 우려 사항에 대한 응답.
  • 정기적으로 또는 요청 시 검토를 요구하는 계정 또는 인증 기관 요구 사항을 충족합니다.

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. 네트워크 제공자는 긴급 상황의 경우 1시간 이내에, 긴급한 상황의 경우 24시간 이내에, 정기 진료 및 전문 진료 의뢰의 경우 7일 이내에 대면 개입을 제공해야 합니다. 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:

  • 회원이 처음으로 약속을 요청한 날짜,
  • 긴급, 긴급 또는 일상과 같은 약속 유형,
  • 첫 번째 약속을 제안한 날짜,
  • 실제 평가 약속 날짜와 시간,
  • 해당되는 경우 표준이 충족되지 않은 이유에 대한 문서.

주요우울증, 양극성장애, 정신분열증, 주의력결핍 과잉행동장애, 동시 발생 정신 및 물질 관련 장애에 대한 진단 지침 및 진단 순응도 지표를 당사 웹사이트에서 참고할 수 있도록 게시하고 있습니다. 제공자 정보 페이지 품질 관리 섹션 아래에 있습니다.