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Provider Responsibilities

 

Quality Assurance and Operation Standards

 

Requirements

 

1.      Provider agrees to comply with the SelectHealth® Quality Improvement Program in all respects, including participating in the member grievance and appeal processes and procedures.

 

2.      Provider agrees to comply with the SelectHealth Utilization Management Program providing preauthorization when required by SelectHealth on identified non-emergent services.

 

3.      Provider understands that, except for emergency situations, services to members should be provided by those entities that have contracted with SelectHealth to provide such services to members.

 

4.      Upon request, SelectHealth agrees to give to provider copies of all quality assurance, utilization management, and operational standards and requirements (and of any changes to such standards and requirements) that the provider must comply with, pursuant to this agreement.

 

5.      Provider agrees to cooperate with credentialing process undertaken by SelectHealth and to cooperate with plans in meeting NCQA accreditation requirements.

 

Record-Keeping Requirements

Specific for Provider and Plan Requirements

 

1.      Provider agrees to maintain all financial and medical records required by law or industry practice for all services rendered to members and to permit a representative of SelectHealth to examine and audit such records upon reasonable advance request.

 

2.      Provider agrees to maintain such records for a period of five years after the rendering of services, and to make such records available for review by SelectHealth and by state and federal authorities and their agents for purposes of assessing medical necessity and the quality and appropriateness of care, and of investigating member grievances and complaints.

 

3.      Provider agrees to maintain all medical records so as to comply with applicable state and federal laws dealing with the privacy and confidentiality of medical records.

 

4.      Provider agrees to provide to SelectHealth, without charge, copies of all records reasonably needed to substantiate claims for payment for facility services.

 

5.      SelectHealth agrees to keep appropriate administrative and claims files and records, and shall upon request give the provider utilization, quality-assessment, and other available records and reports.​


Medical Records Audit Standards

 

SelectHealth monitors the consistency and completeness of medical record documentation to ensure quality patient care. The following Provider Office Medical Record Standards are used to evaluate medical records. We expect 100 percent provider compliance with these standards.

 


Pages Contain Patient ID


Each page in the record should contain patient name or patient ID number.

 


Biographical/Personal Data on Patient


Personal/biographical data should include address, employer, home and work phone numbers, and marital status.

 


Provider Identified on Each Entry


All entries in the medical record should contain author identification. (If the provider is in a solo practice, signing of office notes is optional.) Author identification may be handwritten, stamped, or electronic. Dictated notes do not require initialing.

 


Entries Dated


Each entry should indicate the date of the visit.

 


Legible to Reviewer


The record should be legible to someone other than the writer.

 


Problem List


Significant illnesses and medical conditions should be indicated on the problem list.

 


Allergy and/or Adverse Drug Reactions

 

Medication allergies/adverse reactions should be prominently noted (in an easily recognizable location) on the record. Electronic Medical Record (EMR) computer screen notes and/or EMR hardcopy notes may be used as the prominent location for medication allergies/adverse reactions. The absence of allergies and adverse reaction to medications should also be noted in an easily recognizable location (e.g., NKA – No Known Allergies or NKDA – No Known Drug Allergies).



Past Medical History


Past medical history (for patients seen three or more times) is easily identified including serious accidents, operations, and illnesses. For children and adolescents (ages 18 and younger), past medical history will relate to prenatal care, birth, operations, and childhood illnesses.

 


Smoking/Alcohol/Substance Abuse

 

For patients ages 12 and older, there should be appropriate notation concerning the use of cigarettes, alcohol, and substances (for patients seen three or more times, query substance abuse history). If the patient declines responding, a note indicating this should be present.

 


History and Physical

 

The history and physical exam records the appropriate subjective and objective information pertinent to the patient presenting complaints.

 


Labs and Other Studies Ordered as Appropriate


Labs and other studies ordered should be ordered as appropriate.

 


Plan of Action/Treatment Consistent with Diagnosis

 

The treatment plan described in the medical record should be consistent with the diagnosis.

 


Return Visit or Other Follow-up


Encounter forms or notes should have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return is noted in weeks, months, or as needed. For a healthy patient, a provider may indicate follow-up on a "PRN" (as needed) basis.

 

Problems from Previous Visits Addressed


Unresolved problems from previous visits should be addressed in subsequent visits.

 


Appropriate Use of Consultants


Consultations used should be consistent with the chief complaint and diagnosis.

 


Continuity of Care


If a consult is requested, a note/letter from the consultant should be included in the record.



Consultants, Labs, and Imaging Reports Initialed by Provider

 

Consultation, labs, and imaging reports filed in the chart should have the provider initials to signify review. If the reports are presented electronically or by some other method, they should also show representation of ordering provider review. Consultation, abnormal lab, and imaging study results have an explicit notation in the record of follow-up plans.

 


Immunization Records

 

For children ages 13 and younger, the medical records should contain the date for all immunizations given. For children older than age 13, a notation that "immunizations are up-to-date" will meet the guidelines. For adults ages 19 and older, an appropriate history should be made in the medical record.

 


Preventive Services


There should be some indication that preventive screening and services are being offered in accordance with SelectHealth preventive care practice guidelines.

 


Confidentiality


All medical records should be in compliance with the provider office confidentiality policy and in accordance with the SelectHealth Participating Provider Service Agreement and applicable laws and regulations, such as HIPAA. Providers shall have a policy and/or procedure regarding the release of patient information. The provider shall afford patients the opportunity to approve or refuse the release of identifiable personal information or organization, except when required by law.

 


Chart Format


All records, reports, consultations, summaries, etc., will be secured within the record/folder. There should be records for only one patient in each file. In a family chart, each patient should have his or her own file within the chart. The types of forms used in the medical record and the order in which the forms are placed in the medical record shall be consistent from record-to-record within each practice site.

 


Availability

 

All medical records should be readily available to health providers at each encounter upon request.

 

 

Office Site Visits

 

For member complaints or concerns about quality, an office site visit will be conducted by a SelectHealth Provider Relations representative. Actions will be instituted to improve offices that do not meet standards and evaluate effectiveness of actions at least every six months until a deficit is resolved. Member complaints will be continually monitored and a site visit will be performed within 60 days of the complaint. Follow-up visits for offices that had subsequent deficiencies will be documented.

  

Listed below are the standards that are required and recommended to receive a favorable rating.

 

Standards

 

1. Accessibility and Appearance

 

Required Quality Indicator

  • ​Ability to accommodate the disabled in compliance with state and federal standards (e.g., Americans with Disabilities Act (ADA), handicapped parking, and access).

  • Office is clean, well lit, and provides adequate seating to allow patients to feel comfortable receiving care in the office.

Recommended Quality Indicators

  • ​A reception area that permits observation of the waiting room by the receptionist.

  • Adequate parking to handle the expected volume of patients.

2. Safety

 

Required Quality Indicators

  • ​Fire extinguisher(s) which is(are) routinely checked by a recognized agency according to local ordinances.

  • Building meets local fire/safety code for smoke alarms.

Recommended Quality Indicators

  • ​Visible exit signs.

  • Clear and unobstructed passageways.

  • Evacuation plan and routes posted visibly.

3. Provider Availability

 

Required Quality Indicators

  • Provider will provide 24-hour service for emergency and/or urgent situations for all members. If a provider is not available after regular office hours, he or she must arrange for similar specialty provider coverage (in accordance with the SelectHealth covering provider policy). Rural area providers may direct their phone and/or patients to the hospital for coverage.

  • A method to schedule emergency and urgent visits within the routine office schedule that seeks to minimize unexpected long waiting times for the previously scheduled patients.

Recommended Quality Indicators

  • ​A method to monitor the number of patients actually served per hour compared to the number of scheduled patients per hour.

  • A method to accommodate the scheduling of extra time for visits which usually take longer than the routine visit (e.g., physical examination, a complicated patient, special procedures).

4. Emergency Preparedness

 

Required Quality Indicators

  • ​The members of the office staff are trained in CPR and available during business hours. The office staff is able to describe verbally how they would handle a patient who suffers a life-threatening emergency, such as a heart attack, while in the office.

  • Posted emergency telephone numbers for ambulance, hospital, poison control, and/or 911.

Recommended Quality Indicators

  • If an emergency resuscitation cart is present, procedures for routinely checking the cart for pharmaceutical and sterilized equipment expiration dates and nonfunctional equipment (e.g., dead batteries in the laryngoscope).

  • If a defibrillator is present, education and training by office staff on the proper maintenance and operation of the equipment.

5. Medications

Required Quality Indicators

  • ​The site stores needles, syringes, over-the-counter medications, and prescription medications so that they are accessible only to appropriate office personnel.

  • Prescription pads are inaccessible to patients.

Recommended Quality Indicators

  • ​Date and rotate stock medications.

  • Routinely monitor chug stock for expiration dates.

  • Dispose of expired medications in accordance with applicable hazardous waste laws.

  • Store controlled substances and medications in accordance with state and federal laws.

6. Infection Control

 

Required Quality Indicators

  • The site has a process for disposing of hazardous waste. A system includes designated colored trash bags (red, yellow, red striped) for disposal of hazardous waste and sharps containers. This process should meet state laws if such laws are applicable.

Recommended Quality Indicators

  • If instruments and equipment are used for more than one patient, have an effective sterilization or disinfection method that includes periodic spore testing of sterilizers and proper soaking of instruments in the proper solutions.

7. Patient Education and Patient Rights

 

Required Quality Indicators

  • Informational patient educational programs, pamphlets, or booklets for common medical issues relevant to the type of practice, such as pregnancy and childbirth, diabetes, hypertension, weight loss, or smoking cessation.

  • Concern for patient privacy is demonstrated by protecting disrobed patients from public view or using gowns and/or drapes to cover patients during examinations and closing doors during the patient's visit.

  • Procedures regarding confidentiality and release of information.

  • Knowledge about reportable communicable diseases and health conditions as outlined by the Utah Department of Health.

8. Medical Records

 

Required Quality Indicators

  • ​Confidentiality regulations prohibit a provider from showing a medical record that belongs to a patient who is not a member of SelectHealth. As a result, the reviewer may request to see a sample record. A sample record is one that has been established, usually for office personnel, which demonstrates how a record should be assembled for a new patient. It will not contain a patient identifier or clinical information. Once the provider becomes a participating provider, medical records may be reviewed as part of the review process to assure that the provider is keeping records that meet at least the minimal medical record quality indicators.

  • Medical records adhere to all aspects of the SelectHealth medical records policy, as applicable (e.g., secure/confidential filing system, legible markers, records easily located). ​

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