Quality assurance, Oxford Commercial Supplement - 2022 UnitedHealthcare Administrative Guide

Medical records requirements

As a participating health 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 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 6 years after date of service rendered and for a minor, 3 years after majority or 6 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 7 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 health 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 follow NY and NJ requirements regarding notification of when we receive a credentialing application and when credentialing has been completed. For more information, refer to UnitedHealthcare’s Credentialing Plan and the State and Federal Addendum at uhcprovider.com > Menu > Resource Library > Join Our Network.

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. 

Healthcare effectiveness data and information set measures

The annual Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the National Committee for Quality Assurance (NCQA). NCQA is an independent group established to provide objective measurements of the performance of managed health care benefit plans, including access to care, use of medical services, effectiveness of care, preventive services, and immunization rates, and each benefit plan’s financial status.

CMS, state regulators (commercial) and prospective members use HEDIS measures to evaluate the value and quality of different health plans.

Each year we collect data from a randomly selected sample of our members’ medical records for HEDIS. HEDIS is mandated by the New York Department of Health, New Jersey Department of Health and Senior Services, Connecticut Department of Health, and CMS. The HEDIS medical record study measures our participating health care providers’ adherence to nationally accepted clinical practice guidelines.