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Documentation and Confidentiality of Medical Records - 2019 UnitedHealthcare Adminstrative Guide

Documentation and Confidentiality of Medical Records

You are required to maintain records, correspondence and discussions regarding the member in the strictest of confidence and protection.

You must keep a medical records system that:

  • Follows professional standards
  • Allows quick access of information
  • Provides legible information, accurately documented and available to appropriate healthcare providers
  • Maintains confidentiality

Our member should sign a Medical Record Release Form as a part of their medical record. Call Network Management Services (877-670-8432) to request a copy of this form.

The following guidelines are applicable:

  • Records that contain medical/clinical, social, financial or other data on a patient is treated as confidential and is protected against loss, tampering, alteration, destruction, or inadvertent disclosure;
  • Release of information from your office requires you have the patient sign a Medical Record Release Form. Retain it in the medical record;
  • Release of records is in accordance with state and federal laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA);
  • Records containing information on mental health services, substance use, or potential chronic medical conditions that may affect the member’s plan benefits are subject to additional specific waivers for release and confidentiality.

Exemption from Release Requirements

HIPAA regulation 45 CFR § 164.512 (d) allows us to give PHI to government programs without member permission. We give this when it is necessary to determine member eligibility.

Medical Records Requirements

You must ensure your medical records meet our standards. The following are expanded descriptions of some of these requirements.

Patient Identifiers: Should consist of the patient name and a second unique identifier, and should appear on each page of the medical record.

Advance Directives: It is your responsibility to provide the member with advance directive information, and to encourage the member to retain a copy for their personal records.

Biographical Information: Each record should contain the patient’s name, date of birth, address, home and work phone numbers, marital status, sex, primary language spoken, name and phone number of emergency contact, appropriate consent forms and guardianship information if relevant.

Signatures: For paper medical records, have all entries dated and signed or initialed by the author. Author identification may be a handwritten signature or initials followed by the title (MD, DO, PA, ARNP, RN, LPN, MA or OM). There must be a written policy requiring, and evidence of, physician co-signature for entries made by those other than a licensed practitioner (MD, DO). Electronic signatures are acceptable for electronic medical records.

Family History: Document the family history no later than the first visit.

Past Medical History: Documentation should include a detailed medical, surgical and social history.

Immunizations: Documentation of immunizations performed by the office should include the date the vaccine was administered, the manufacturer and lot number, and the name and title of the person administering the vaccine. At a minimum, you must have their vaccination history.

Medication List: List the member’s current medications, with start and end dates, if applicable. Reconcile within 30 days post inpatient admissions.

Referral Documentation: If a referral was made to a specialist, the consultation report should be filed in the medical record. There should be documentation the physician has discussed abnormal results with the patient, along with recommendations.

Chart Organization: You should maintain a uniform medical record system of clinical recording and reporting with respect to services, which includes separate sections for progress notes and the results of diagnostic tests.

Preventive Screenings: You need to promote the appropriate use of age/gender specific preventive health services for members to achieve a positive impact on the member’s health and better medical outcomes.

Required Encounter Documentation: For every visit, document the following:

  • The date;
  • Chief complaint or purpose;
  • Objective findings;
  • Diagnosis or medical impression;
  • Studies ordered (lab, x-ray, etc.);
  • Therapies administered or ordered;
  • Education provided;
  • Disposition, recommendations, instructions to the member and evidence of whether there was follow-up; and
  • Outcome of services.

You must document you have a written policy in place regarding follow- up care and written procedures for recording results of studies and therapies and appropriate follow-up.

As a part of their medical record, members should sign a Medical Record Release Form. They should sign a Refusal Form when declining a preventative screening referral.

We recommend medical records include copies of care plans whenever you provide home health or skilled nursing services.

Case Management and Disease Management Program Information

Optum provides Case Management (CM) and Disease Management (DM) services for Medica HealthCare.

Here are the criteria for referrals to Optum Case Management and Disease Management Programs:

  • Complex Case Management — (Special Needs Plan (SNP) members only)
  • Three or more unplanned admissions and/or Emergency Room (ER) visits in the last six months or
  • Multiple, complex co-morbid conditions and/or
  • Coordination of multiple community resources/financial supports to cover basic services
  • Heart Failure (HF) Disease Management Program
  • Diagnosis of HF and
  • Has CHF on an inpatient claim or
  • HF admission in last three months
  • Diabetes Disease Management Program
  • Diabetic with A1C 9% or greater or
  • An inpatient admission related to diabetes in the past 12 months or
  • Two or more ER visits related to diabetes
  • Advanced Illness Case Management — Primary goal is to facilitate and support end of life wishes and services
  • Life expectancy of 12 - 18 months
  • Chronic, irreversible disease or conditions and declining health
  • Reduce disease and symptom burden
  • Transplant Case Management and Network Services Bone marrow/stem cell, kidney and kidney/pancreas, heart, liver, intestinal, multi-organs and lung transplants
  • Case management for one year post-transplant
  • End Stage Renal Disease Case Management — The member is diagnosed with end stage renal disease and is undergoing outpatient dialysis including in-center or home hemodialysis, home peritoneal dialysis, etc. If the member does not qualify for one of the above programs, they do have 24/7, 365 days a year access to speak with a nurse by calling the Optum NurseLine number on the back of their ID card.

NOTE: South Florida Medica no longer provides Social Worker evaluations without skilled services. Please direct your patient to their local social services department or The Florida State Department of Elder Affairs Help Line at 800-963-5337.

To request Case Management and Disease Management services for one of our members, select only one program that your member meets the criteria for, and email the CM/DM referral form, available on medicaplans.com > Physicians and Providers > Provider Forms, to southfl@optum.com.

When appropriate, we provide referrals to other internal programs such as disease management, complex condition management, mental health, employee assistance and disability. Case management services are voluntary and a member may opt out at any time.

Optum Behavioral Health

We work with Optum Behavioral Health to provide behavioral healthcare services for our members. For more information on how to access the Behavioral Healthcare programs, you or our members may contact a representative through the phone number listed on the back of their health care ID card.

Special Needs Plans (SNP)

Special Needs Plan Model of Care

The Model of Care (MOC) is the framework for care management processes and systems to help enable coordinated care for SNP members. The Model of Care contains specific elements that delineate implementation, analysis and improvement of care.

These elements include description of SNP population (including health conditions), Care Coordination, Provider Network and Quality Measurement and Performance Improvement.

The Model of Care is a quality improvement tool and Model of Care helps ensure the unique needs of our SNP members are identified and addressed through care management practices. Model of Care goals are evaluated annually to determine effectiveness. To learn more, contact us via email at: snp_moc_providertraining@uhc.com.

The Centers for Medicare and Medicaid (CMS) requires annual SNP Model of Care training for all care providers who treat SNP members. View the Annual SNP Model of Care Provider Training in our Training section. Reminders about the training requirements are communicated annually through the Network Bulletin described in Chapter 17.

Risk Management

Risk management addresses liability, both proactively and reactively. Proactive is avoiding or preventing risk. Reactive is minimizing loss or damage after an adverse or bad event. Risk management in health care considers patient safety, quality assurance and patients’ rights. The potential for risk is present in all aspects of health care, including medical mistakes, electronic record keeping, provider organizations and facility management.

An adverse event is defined as an event over which healthcare personnel could exercise control rather than as a result of the member’s condition. Identifying something as an adverse event does not imply “error,” “negligence,” or poor quality care. It simply indicates an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. Examples of adverse events in health care include unexpected death, failure to diagnose or treat disease, or surgical mistakes or accidents. Adverse events interfere with a care provider’s delivery of medical care and may result in litigation.

Agency for Healthcare Administration (AHCA)

The Florida Agency for Healthcare Administration (AHCA), as directed under F.S. 641 Parts I, II, III and other applicable state laws, provides oversight and monitoring of health plans operating in the State of Florida as an HMO and their compliance to applicable regulations.

This includes implementation of a Risk Management Program (RMP) with the purpose of identifying, investigating, analyzing and evaluating actual or potential risk exposures by a state licensed risk manager. The Risk Management Program also corrects, reduces and eliminates identifiable risks through instruction and training to staff and care providers.

Examples of adverse and serious incidents as defined by AHCA include:

  • Death of a patient;
  • Severe brain or spinal damage to a patient;
  • Performance of a surgical procedure on the wrong patient;
  • Performance of a wrong site surgical procedure; or
  • Performance of a wrong surgical procedure.

For more information, go to the Agency for Healthcare Administration website at ahca.myflorida.com.