Manual do Provedor

AVALIAÇÕES DE REGISTRO DE TRATAMENTO

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

• Em resposta a um problema específico de qualidade ou preocupação que surge.
• Para atender aos requisitos de conta ou agência de credenciamento que exigem revisão periódica ou mediante solicitação.

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. Um provedor de rede deve fornecer intervenções face a face dentro de uma hora para emergências, dentro de 24 horas para situações urgentes e dentro de sete dias para consultas de rotina e encaminhamentos para especialidades. 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:

• A data da chamada inicial do membro para uma reunião,
• O tipo de consulta, como emergência, urgente ou de rotina,
• A data da primeira consulta oferecida,
• A data e a hora da consulta de avaliação real, e
• A documentação do motivo pelo qual a norma não foi atendida, se aplicável.

Diretrizes diagnósticas e indicadores de adesão diagnóstica para depressão maior, transtorno bipolar, esquizofrenia, transtorno de déficit de atenção e hiperatividade e transtornos mentais e relacionados a substâncias concomitantes são postados em nosso site para referência no Página de informações do provedor na seção Gerenciamento de qualidade.