Provider Relations (314) 214-8137 Or (800) 596-4315

Provider Relations (314) 214-8137 or (800) 596-4315

Prior Authorization (314) 214-8282 or (800) 647-2240

III.5 Medical Records

Mercy Health Plans, Inc. (MHP) has adopted guidelines for the maintenance of medical records within participating physician offices that supports consistent and complete documentation of each member’s medical history and treatment. Appropriate documentation is an essential component of quality care. Medical records guidelines and review procedures have been developed to comply with NCQA, HCFA and other nationally recognized standards.

The following recommendations will be reviewed and revised if necessary at least annually by the Quality Improvement Committee. At the time of initial credentialing and upon recredentialing, if applicable, MHP may review a sampling of the physician’s files to determine compliance with the guidelines in force at the time of the review. As guidelines and review tools are revised, updated information will be shared with participating physicians.

Medical records guidelines include:

 Medical records are confidential documents. Each physician office shall have policies and procedures in place regarding confidentiality and retention that comply with State requirements. At a minimum, medical records must be retained for the longer of seven years and/or seven years after the age of patient majority or as required by the State.

 Medical records are to be systematically organized to allow for efficient review. We recommend that you firmly attach all documents to the patient’s record. Individual medical records are recommended as opposed to family medical records. If family medical records are maintained, each patient’s component of the record should be clearly distinguishable and organized.

 Medical records are legible to individuals other than the writer.

 All individuals who enter information within the document are clearly identified.

 The patient’s name and other appropriate identifying information are to be indicated on each page of the file. Personal/biographical information is contained within the file and includes:

 Marital status

 Family information

 Address and phone numbers

 Employer name

 Past medical history and treatments, including a problem list outlining significant illnesses and medical conditions, food and/or drug allergies and adverse reactions (including “no known allergy” information), prior accidents, operations or illnesses, documentation of smoking habits and/or history of substance abuse and other health risk factors are clearly identified within the medical record.

 All entries are dated and signed.

 The record of the visit includes the reason for the encounter, relevant history and physical exam findings (including subjective and objective information), and documentation of prior diagnostic test results. Records include information on unresolved problems from past medical visits.

of 2  Working diagnoses are documented and are consistent with the findings.

 Treatment plans are consistent with the diagnosis and there is no evidence that the patient is placed at an inappropriate risk by a particular diagnostic or therapeutic procedure.

 Notations regarding follow-up calls or visits for unresolved problems are identified. The clinician or other office staff member notes follow-up information.

 Note when the patient was offered and received preventive screening and services according to nationally recognized practice guidelines. The medical record should indicate when test results were reviewed by the physician and shared with the patient.

 Reason for consultation, lab and other diagnostic testing and follow-up treatment are clearly outlined in the patient’s medical file and medically appropriate for the working diagnosis. When consultants are requested, the requesting physician will make applicable medical record information available to the consulting physician.

 Consultant notes, lab and imaging and other diagnostic test reports are initialed and dated by the reviewing physician. Information is contained within the medical record indicating when the patient or appropriate responsible party was notified of the results. If the results are abnormal, there must be explicit notes regarding follow-up plans.

 For children, a complete immunization record must be available within the record.

 Medical records should support the ICD9 and CPT4 coding reported to health insurance companies.

Confidentiality of Medical Records

Medical records of members must be treated as confidential so as to comply with state and federal laws and regulations. Providers should maintain the confidentiality of all information contained in a member’s medical record and only release such records and/or information: a) in accordance with the provisions in the signed Provider Agreement, b) subject to applicable laws, regulations or orders of any court pf law, c) as necessary, to other providers treating a member, or d) with the written consent of the member.

Availability and/or Transfer of Medical Records

When a member changes his/her Primary Care Physician, he/she may request a transfer of medical records or copies of medical records. These records must be forwarded at no charge to MHP or the member to the new provider within ten (10) business days from receipt of the request or prior to the member’s next scheduled appointment with the new provider.

Participating physicians and other providers including, but not limited to, facilities are required to assist with MHP’s Quality Improvement and Utilization Management activities. In many instances, this is accomplished by making medical records available to the appropriate health plan representative. In addition, authorized representatives from Medicaid, the Health Department, the Department of Health and Human Services and/or HCFA are allowed access to patient records of Mercy MC+ and PremierPlus members for specific purposes. To facilitate the process, all members sign a release of medical information as part of their enrollment process. This release is in effect for the duration of their status as an MHP plan member.

When possible, MHP will give your office thirty (30) days advance notice of the need for any medical record review. Providers may accept a reasonable copying charge of $0.10 per page for copies of such records. However, providers may not charge MHP for copying requested records when that request is related to the processing of a claim.

Created - December 1995 Revised - August 2002