DCS Comprehensive Health Plan

Medical Record Review

Policy Statement

This policy sets forth the guidelines used by DCS Comprehensive Health Plan (DCS CHP) when conducting medical record reviews.

Definitions

Medical Records: a chronological written account (digital or analog) of a patient's examination and treatment that include but is not limited to the;

• patient's medical history and complaints,

• provider's physical findings, behavioral health findings,

• results of diagnostic imaging, tests, procedures

• medications and therapeutic procedures,

• referrals and treatment plans.

Provider: an AHCCCS registered medical, dental or behavioral health care professional.

National Committee Quality Assurance (NCQA): is a private, 501 (c)(3) not-for profit organization dedicated to improving health care quality.

Policy

The DCS Comprehensive Health Plan (DCS CHP), in partnership with its contracted Managed Care Organization (MCO), requires providers to maintain accurate and current, medical records for members. Providers’ medical record documentation, physical or electronic, should reflect a member’s health conditions and status, health care needs and health services provided, in order to provide continuous, quality, effective and comprehensive health care and to allow for effective coordination of care and ease of quality review.

DCS CHP through its contracted MCO conducts periodic medical record reviews with providers as part of its Quality Management Performance Improvement (QM/PI) Program. Medical records reviewed include Ambulatory Medical Record Review (AMRR) and the Behavioral Health Clinical Chart Audit. Medical record review results are shared with providers to assure ongoing compliance with documentation standards.

The medical record review process assures:

• Fulfillment of regulatory requirements; and

• Ongoing support of clinical quality improvement and coordination of care activities.

DCS CHP and its contracted MCO comply with medical record review requirements in accordance with Federal and State statutes and regulations, and AHCCCS policy and contracts. Medical record requirements are applicable to both hard copy and electronic medical records.

Paper and Electronic Health Records (EHR)

Providers are instructed to maintain comprehensive medical records and to safeguard the privacy of medical records and patient information in accordance with Title 9 of the Arizona Administrative Codes, Chapter 22, Article 5, as well as incorporate the requirements outlined in the AHCCCS Medical Policy Manual (AMPM), 940, Medical Records and Communication of Clinical Information.

DCS CHP and its contracted MCO require providers who maintain Electronic Health Records (EHR) and digital (electronic) signatures, to certify that that EHR use and policy meets federal and state requirements, including those related to security and privacy, including but not limited to 45 CFR 160, 162, and 164, 42 CFR 431.300 et seq. and Medicaid Information Technology Architecture (MITA).

EHR and policies must comply with specific requirements that include:

• Electronic signature authentication;

• Message or document authentication/integrity;

• Nonrepudiation or affirmative act that establish that the signatory individual affirms the validation of the electronic presentation;

• Efficiency;

• Medical record review; and

• Confidentiality of the member medical record

Procedure

Participation

DCS CHP and its contracted MCO participate in the Arizona Association of Health Plans (AzAHP) Alliance to conduct collaborative medical record reviews to monitor the quality of physical health preventative care and treatment, and behavioral health care of DCS CHP members.

The collaboration through AzAHP utilizes a mechanism for medical record review which results in only one medical record review for each provider. Results of the reviews are made available to all Contractors who utilize the AzAHP for this process and contract with the audited providers. This approach reduces the burden to provider offices by decreasing the number of parties requesting medical records.

AMRR medical record reviews are conducted by appropriately licensed staff, utilizing an AHCCCS approved standardized tool, at a minimum every three years. Providers subject to AMRR include:

• Primary Care Providers;

• Obstetrics and Gynecology Providers;

• Dental Providers of EPSDT services.

The medical record/chart review consists of, but is not limited to, reviewing compliance related to the following areas:

• General Medical Record Documentation;

• EPSDT specific elements including developmental screening;

• Medical/Social History/Medical Management;

• Health Maintenance (Laboratory/Diagnostic Studies);

• Behavioral Health;

• Family Planning;

• Maternity care.

The review process includes the following:

• Review of charts per practitioner as determined by the collaborative AzAHP protocol;

• Scores that do not meet the established collaborative standard for the provider category may result in technical assistance that is provided to practitioner, the provider may be required to develop and implement a corrective action plan and practitioner will be re- audited the following year;

• Score over 90%, technical assistance is provided as needed for areas of deficiencies.

Behavioral Health Clinical Chart Audits are conducted by appropriately licensed staff with the appropriate experience necessary, utilizing a standardized too which includes elements specific to the DCS CHP population at a frequency indicated by the Behavioral Clinical Chart Audit Methodology and Findings Summary Report outlined in contract.

Providers subject to behavioral health Clinical Chart Audit include:

• Behavioral Health outpatient Clinics;

• Integrated Health homes and Federally Qualified Health Care Centers (FQIH) if they provide both behavioral health and physical health care.

Behavioral health records reviews include, but are not limited to:

• Elements that pertain to assessment;

• Service/treatment planning;

• Elements that address the unique needs of the DCS CHP population which may also include elements that address:

  • Serious mental illness;

  • Special health care needs;

  • Presence in foster care;

  • Services that address mental health in the context of developmental delays.

Providers who do not pass the medical record review or have areas of deficiency are provided with technical assistance, may have a focused review or be required to develop and implement a corrective action plan until the providers’ medical records meet standards. These providers are re-audited again in the following year.

If during the process of medical record review, quality of care issues are identified, DCS CHP informs the other health plans in the alliance of the issue within 24 hours, to allow for independent on-site provider audits.

Results of record reviews, deficiencies and identified Quality of Care issues are shared with the AzAHP alliance and MCOs who contract with the specific provider.

DCS CHP coordinates regularly with AzAHP Alliance through regular meetings to support the collaborative process and report any deficiencies as they are identified.

Confidentiality and Disclosure of Confidential Information

DCS CHP and its contracted MCO maintain protection and confidentiality of member medical records, and information contained therein, in accordance with Federal and State statutes and regulations, including but not limited to the Health Insurance Portability and Accountability Act. (See DCS Administrative Policy, DCS 07-16, HIPAA Privacy).