Manwal ng Tagabigay

MGA REBYONG REBAHO NG PAGTATARA

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

• Bilang tugon sa isang tukoy na isyu sa kalidad o pag-aalala na lumitaw.
• Upang matugunan ang mga kinakailangan sa account o accreditation ahensya na nag-uutos sa pagsusuri sa isang pana-panahong batayan o kapag hiniling.

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. Ang isang tagapagbigay ng network ay dapat magbigay ng mga interbensyon na harapan sa loob ng isang oras para sa mga emerhensiya, sa loob ng 24 na oras para sa mga kagyat na sitwasyon, at sa loob ng pitong araw para sa mga regular na appointment at referral ng specialty. 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:

• Ang petsa ng paunang tawag ng miyembro para sa isang appointment,
• Ang uri ng appointment, tulad ng emergency, urgent o routine,
• Ang petsa ng unang appointment na inaalok,
• Ang petsa at oras ng aktwal na appointment ng pagsusuri, at
• Ang dokumentasyon ng dahilan ng pamantayan ay hindi natutugunan, kung naaangkop.

Ang mga patnubay sa diagnostic at tagapagpahiwatig ng pagsunod sa diagnostic para sa pangunahing pagkalumbay, bipolar disorder, schizophrenia, hyperactivity disorder na may attention-deficit, at mga magkakasamang sakit na nauugnay sa pag-iisip at sangkap ay nai-post sa aming website para sa sanggunian sa Pahina ng Impormasyon ng Tagabigay sa ilalim ng seksyon ng Pamamahala ng Kalidad.