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Quality Improvement: Guidelines and Resources

Medical Record Review Provider Audit:

The importance of having standards is to verify that Providers:

■ Are aware of the expected level of care and associated documentation,

■ Are aware of the requirements for maintenance of confidential medical information and record keeping, and

■ Are assured that medical records are being evaluated in a consistent manner.

Goals:

  • The Quality Improvement/Utilization Management Committee has established the scoring standard of 80% for the Medical Record Review elements.
  • If the score of 80% has not been met for MRR, a follow–up review will be scheduled to assess improvement.
  • Providers are notified of their results and any areas of deficiency by letter within forty-five (45) calendar days of the review.
  • Repeatedly failing to meet an overall performance score of 80% may lead to initiation of corrective action, up to and including termination from the Plan.

Frequency of Reviews:

  • Medical record reviews are conducted annually on a sample of PCPs, Specialists, and Behavioral Health Providers. Medical records for this review are obtained directly from the provider and may be reviewed at the provider’s location (on-site review) or sent to Highmark Health Options for a desk-top review.

Notifiable Diseases and Conditions:

The State of Delaware requires providers to report certain diseases, infections, conditions and outbreaks such as, but not limited to, chicken pox, lead poisoning, Lyme disease, and mumps . A full listing of notifiable diseases can be found at http://dhss.delaware.gov/dph/dpc/rptdisease.html. This listing provides instructions for reporting and includes those conditions identified as “rapidly” reportable to the Delaware Division of Public Health.

[1] Delaware Administrative Code, 16 DE Admin Code 4202 Control of Communicable and Other Disease Conditions, Section 2.0