Superior HealthPlan providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. They will also enable Superior HealthPlan to review the quality and appropriateness of the services rendered. Superior HealthPlan will conduct random medical record audits as part of its QI program to monitor compliance with the medical record documentation standards.
The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services also may be assessed during a medical record audit. Superior HealthPlan will provide written notice prior to conducting a medical record review.
Below are some guidelines for Medical Record Maintenance:
- Practitioners are required to maintain all records for members for at least 7 years from the anniversary date of the date of last treatment by the physician.
- If a patient is younger than 18 years of age when last treated by the physician, the medical records of the patient shall be maintained by the physician until the patient reaches 21 years of age, or for 7 years from the date of last treatment, whichever is longer.
- Practitioners and providers must keep accurate and complete medical records that are legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided including, but not limited to, examination notes, imaging and laboratory test results, prescriptions, and referrals; as well as salient documentation of medical services received by the member while inpatient, including hospital discharge summaries, ambulatory, ancillary, emergency care, specialty care, and home health reports received.
- Medical records must be prepared in accordance with all applicable State and Federal rules and regulations and signed by the medical professional rendering the services.
- Medical records must be accessible at the site of the member’s participating Primary Care Physician (PCP) or Provider (see definitions).
- To ensure the member’s privacy, medical records shall be kept in a secure location that allows access only by authorized personnel.
- Practitioners/Provider are required to maintain all records for members for at least seven years from the anniversary date of the date of last treatment by the physician.
- If a patient is younger than 18 years of age when last treated by the physician, the medical records of the patient shall be maintained by the physician until the patient reaches age 21 or for seven years from the date of last treatment, whichever is longer.
- Practitioner/provider staff shall receive periodic training in Member PHI and Health Insurance Portability and Accountability Act (HIPAA) training.
For frequently asked questions on Superior’s Medical Records Request process, please review Superior’s Medical Records Requests and Provider Release of Protected Health Information (PHI) FAQ (PDF).