提供者手册

治疗记录审查

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

  • 针对出现的特定质量问题或关注。
  • 为了满足帐户或认证机构的要求，定期或应要求进行审查。

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. 对于紧急情况，网络提供商必须在1小时内提供面对面的干预，对于紧急情况，必须在24小时内提供面对面的干预，对于常规约会和专职转诊，则必须在7天内提供面对面的干预。 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:

  • 成员首次预约的日期，
  • 任命的类型，例如紧急，紧急或常规，
  • 提供第一次约会的日期，
  • 实际评估任命的日期和时间，以及
  • 不符合标准的原因的文档（如果适用）。

有关严重抑郁，双相情感障碍，精神分裂症，注意力缺陷多动障碍以及同时发生的精神和物质相关障碍的诊断指南和诊断依从性指标已发布在我们的网站上，以供参考。 提供商信息页面 在质量管理部分下。