All MHP providers are required to participate in MHP’s QI activities as stated in the provider/practitioner contract, which includes medical record audits/reviews. Medical record audits/reviews will be conducted in compliance with regulatory and internal reporting requirements, which include but are not limited to:
HEDIS;
Adverse Event Investigations;
Fraud, Waste & Abuse;
Corporate Appeals;
Benefit Determination,
Benefit Exceptions, Claims Processing;
Health and Wellness Initiatives;
Case Management;
Disease Management;
Quality Improvement Projects and Quality Incentive Projects;
Medicare Operations; and
Evaluation of provider practice and adherence to documentation standards.
Reviews/Audits may be performed annually and/or on an as-needed basis.
Review of Medical Records may be conducted onsite or requested for an offsite review. Audits will be conducted utilizing specific abstraction tools following an established procedure for provider notification and scheduling.
Protected health information (PHI) will be utilized and shared only to the extent required for job duties and as permitted under state and federal law. All employees, committee members, board members and participating providers will preserve the confidentiality of PHI consistent with state and federal law. All medical records obtained by MHP will be maintained in a secure location as specified for action/department conducting the review/audit.
Medical records are confidential documents. All MHP representatives shall maintain member and provider confidentiality when reviewing and/or handling medical records.
Confidential. Property of Mercy Health Plans. Shall not be used, reproduced or disclosed without Mercy Health Plans’ express consent.
© 2009 Mercy Health Plans.
SL-CO-063-0809 Version 1
[1]Participating physicians have agreed to provide or to arrange for the provision of urgent and emergent medical care 24 hours per day, seven days per week for members.