Clinical Guidelines

Clinical Practice Guidelines

Clinical Practice Guidelines can be used to help direct care based on best available evidence based practices in order to reduce inappropriate variation in practice and provide best care for members.

Medical Record Review Audit

Medical Record Review (MRR) Standards have been adopted by the Highmark Health Options Quality Improvement and Utilization Management (QI/UM) Committee. The importance of having standards is to verify that providers are:

  • Assured that medical records are being evaluated in a consistent manner.
  • Aware of the expected level of care and associated documentation.
  • Aware of the requirements for maintenance of confidential medical information and record keeping.

The following MRR Standards have been developed:

Goals

  • The Quality Improvement/Utilization Management Committee has established the scoring standard of 80% for the MRR 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 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 MCO.

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 on-site location or sent to Highmark Health Options for a desktop 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 is available on the Delaware Division of Public Health website. This listing provides instructions for reporting and includes those conditions identified as rapidly reportable to DHSS.

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