Medical Record Review. Health Plan shall be entitled to perform concurrent or retrospective reviews of medical records for utilization management purposes or to verify that items and services billed to or paid for by Health Plan were provided and billed correctly in accordance with this Agreement and the Provider Manual, or were Covered Services (including that such items and services were Medically Necessary).
Medical Record Review. PacifiCare shall on an ongoing basis review medical records maintained by Medical Group and its Participating Providers to assess compliance with the requirements of State and Federal Law and the standards of Accreditation Organizations. Medical Group and its Participating Providers shall maintain medical records in accordance with the provisions of this Agreement regarding medical records and in accordance with PacifiCare’s guidelines regarding medical records.
Medical Record Review. The INSURER will establish a program to monitor the appropriateness of care being provided, the adequacy and consistency of record keeping, and completeness of records, as described in the INSURER's Proposal. The INSURER shall notify the ADMINISTRATION on a quarterly basis of all findings in the Medical Record Review Program. The ADMINISTRATION may review and/or audit Program records and reports at any time.
Medical Record Review. (1) If the Health Plan is not accredited, or if the Health Plan is accredited by an entity, that does not review the Medical Records of the Health Plan's PCPs, then the Health Plan shall conduct reviews of Enrollees’ Medical Records to ensure that PCPs provide high quality health care that is documented according to established standards.
(2) The standards, which must include all Medical Record documentation requirements addressed in this Contract, must be distributed to all Providers.
(3) The Health Plan must conduct these reviews at all PCP sites that serve fifty (50) or more Enrollees.
(4) Practice sites include both individual offices and large group facilities.
(5) The Health Plan must review each practice site at least one (1) time during each two (2) year period.
(6) The Health Plan must review a reasonable number of records at each site to determine compliance. Five (5) to ten (10) records per site is a generally-accepted target, though additional reviews must be completed for large group practices or when additional data is necessary in specific instances.
(7) The Health Plan shall report the results of all Medical Record reviews to the Agency within thirty (30) Calendar Days of the review.
(8) The Health Plan must submit to the Agency for written approval and maintain a written strategy for conducting Medical Record reviews. The strategy must include, at a minimum, the following:
(a) Designated staff to perform this duty;
(b) The method of case selection;
(c) The anticipated number of reviews by practice site;
(d) The tool that the Health Plan will use to review each site; and
(e) How the Health Plan will link the information compiled during the review to other Health Plan functions (e.g., QI, credentialing, Peer Review, etc.).
Medical Record Review. Health Plan shall on an ongoing basis review medical records maintained by Medical Group and its Participating Providers to assess compliance with the requirements of State and Federal Law and the standards of Accreditation Organizations. Medical Group and its Participating Providers shall maintain medical records in accordance with the provisions of this Agreement regarding medical records and in accordance with guidelines regarding medical records set forth in the Provider Manual.
Medical Record Review. Medical and psychological records will be obtained from the candidate’s/officer’s treating health professional, if warranted and obtainable.
Medical Record Review. If the Health Plan is not accredited, the Health Plan shall conduct reviews of enrollees’ medical records to ensure that PCPs provide high quality health care that is documented according to established standards, including subparagraphs (2) through (7) below.
Medical Record Review. (1) If the Health Plan is not accredited, the Health Plan shall conduct reviews of enrollees’ medical records to ensure that PCPs provide high quality health care that is documented according to established standards, including subparagraphs (2) through (7) below.
(2) The standards, which must include all medical record documentation requirements addressed in this Contract, must be distributed to all providers.
(3) The Health Plan shall conduct these reviews at all PCP sites that serve ten (10) or more enrollees.
(4) Practice sites include both individual offices and large group facilities.
(5) The Health Plan shall review each practice site at least once every three years. AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract
(6) The Health Plan shall review a reasonable number of records at each site to determine compliance. Five (5) to ten (10) records per site is a generally- accepted target, though additional reviews must be completed for large group practices or when additional data is necessary in specific instances.
(7) The Health Plan shall submit to BMHC for written approval, and maintain, a written strategy for conducting medical record reviews. The strategy must include, at a minimum, the following:
(a) Designated staff to perform this duty;
(b) The method of case selection;
(c) The anticipated number of reviews by practice site;
(d) The tool that the Health Plan will use to review each site; and
(e) How the Health Plan shall link the information compiled during the review to other Health Plan functions (e.g., QI, credentialing, peer review, etc.).
Medical Record Review. (1) If the Health Plan is not accredited, the Health Plan shall conduct reviews of enrollees’ medical records to ensure that PCPs provide high quality health care that is documented according to established standards, including subparagraphs (2) through (7) below.
(2) The standards, which must include all medical record documentation requirements addressed in this Contract, must be distributed to all providers.
(3) The Health Plan shall conduct these reviews at all PCP sites that serve ten (10) or more enrollees.
(4) Practice sites include both individual offices and large group facilities.
(5) The Health Plan shall review each practice site at least once every three years. HealthEase of Florida, Inc. Medicaid HMO Non-Reform Contract
(6) The Health Plan shall review a reasonable number of records at each site to determine compliance. Five (5) to ten (10) records per site is a generally-accepted target, though additional reviews must be completed for large group practices or when additional data is necessary in specific instances.
(7) The Health Plan shall submit to BMHC for written approval, and maintain, a written strategy for conducting medical record reviews. The strategy must include, at a minimum, the following:
(a) Designated staff to perform this duty;
(b) The method of case selection;
(c) The anticipated number of reviews by practice site;
(d) The tool that the Health Plan will use to review each site; and
(e) How the Health Plan shall link the information compiled during the review to other Health Plan functions (e.g., QI, credentialing, peer review, etc.).
Medical Record Review. Provider agrees to cooperate in Utilization Review programs for the purpose of avoiding unnecessary or unduly costly Covered Services while ensuring the delivery of quality health care for Injured Worker(s). Plan may conduct medical record review of Claims submitted by Participating Provider prior to payment. Neither Plan nor the Injured Worker(s) shall be obligated to pay for any services that Plan determines to be Medically un-Necessary, and Participating Provider agrees not to bill Injured Worker(s) for such services.
