Medical Record Standards

Provider Medical Record Standards have been adopted by the Highmark Health Options Quality Improvement and Utilization Management (QI/UM) Committee. The importance of having standards is to confirm that health care 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.

Performance Scoring

• The QI/UM Committee has established the scoring standard of 80% for the medical record elements.
• If the score of 80% has not been met for the medical record standards, then a follow-up review will be scheduled to assess improvement.
• Providers are notified of their results and any areas of deciency 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.

Review Frequency

The Provider Medical Record Audit is 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.