Руководство поставщика

ОБЗОРЫ ЗАПИСЕЙ О ЛЕЧЕНИИ

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

  • В ответ на конкретную проблему качества или проблему, которая возникает.
  • Для выполнения требований учетной записи или агентства по аккредитации, предусматривающих проверку на периодической основе или по запросу.

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 fifteen (15) calendar days of such request and at no expense to Carelon.

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. Сетевой поставщик услуг должен обеспечить очное вмешательство в течение одного часа в экстренных случаях, в течение 24 часов в случае неотложных ситуаций и в течение семи дней в случае обычных приемов и направлений к специалистам. 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:

  • Дата первоначального звонка члена о встрече,
  • Тип встречи, такой как экстренная, срочная или плановая,
  • Дата первой предложенной встречи,
  • Дата и время фактического назначения оценки, и
  • Документация о причине несоблюдения стандарта, если применимо.

Диагностические рекомендации и индикаторы приверженности диагностике большой депрессии, биполярного расстройства, шизофрении, синдрома дефицита внимания и гиперактивности, а также сопутствующих психических расстройств и расстройств, связанных с употреблением психоактивных веществ, размещены на нашем веб-сайте для ознакомления на Информационная страница провайдера в разделе «Управление качеством».