Quality Assurance, Oxford - 2020 UnitedHealthcare Administrative Guide

Quality Assurance

Medical Records Requirements

As a participating care provider or other health care professional, you must provide us with copies of medical records for our members within a reasonable time period following our request for the records. We may request records for various reasons, including an audit of your practice. An audit may be performed at our discretion and for several different purposes as we deem appropriate for our business needs.

Standards for Medical Records

A comprehensive, detailed medical record is vital to promoting high-quality medical care and improving patient safety. Our recommended medical record standards are published each November for commercial benefit plans in the Network Bulletin at UHCprovider.com/news > Network Bulletin. Our requirements include, but are not limited to:

  • Separate medical record for each member.
  • The record verifies the PCP is coordinating and managing care.
  • Medical record retention period of six years after date of service rendered and for a minor, three years after majority or six years after the date of the service, whichever is later.
  • Prenatal care only: A centralized medical record for the provision of prenatal care and all other services.

Transferring Member Medical Records

If you receive a request from a member to transfer their medical records, do so within seven days to help ensure continuity of care. To safeguard the privacy of the member’s records, mark them as “Confidential.” Be sure no part of the record is visible during transmission.

Electronic Medical Records

An electronic medical record (EMR) is any type of electronic concurrent medical information management system. This process improves efficiency and quality inpatient care through integrated decision support which provides better information storage, retrieval and data sharing capabilities. EMR systems allow care providers, nurses and other health care staff to access and share information smoothly and quickly, enable them to work more efficiently, and make better-quality decisions.

UnitedHealthcare’s Credentialing and Re-credentialing Notifications

We complete our credentialing process and give notification of the results (within 60 days for NY, 45-60 days for NJ) of receiving a completed application. The notification tells you whether you are credentialed, if more time is needed, or if UnitedHealthcare is not in need of additional care providers at this time. If more information is needed, we notify the applicant ASAP but no more than 90 days from the receipt of the application.

For more information on our credentialing program, refer to Chapter 14: Credentialing and Re-Credentialing.

Healthcare Provider Performance Evaluations UnitedHealthcare is required to provide health care professionals with any information and profiling data used to evaluate your performance. Periodically, and at your request, we provide the information, profiling data and analysis used to evaluate your performance. You are given the opportunity to discuss the unique nature of your patient population which may have bearing on your profile and we work with you to improve your performance as needed.