2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care Coordination14. An initial PCP contact or routine physicalexamination indicates a substance abuseproblem;15. A prenatal visit indicates substance abuseproblems;16. Positive response to questions indicatessubstance abuse, observation of clinicalindicators or laboratory values that indicatesubstance abuse;17. A pattern of inappropriate use of medical,surgical, trauma or emergency roomservices that could be related to substanceabuse or other Behavioral Health conditions;and/or18. The persistence of serious functionalimpairment.For additional detail on procedures for authorizationof behavioral health services, please refer to theBehavioral Health chapter of this manual.Medical Record ReviewsMedical record reviews are performed for primarycare practitioners, OB/GYN practitioners, and highvolumebehavioral health specialists. The followingcriteria apply:A passing score of 85 percent is required.If the medical record review score is less than85 percent, Presbyterian may choose to doany or all of the following:• Identify deficiencies and send a letter tothe provider that identifies complianceissues• Suggest an action plan for improvement,and send an example education form• Publish best practices for medical recorddocumentation in the provider newsletter• Coordinate with Provider Services formedical record review follow-upPresbyterian Access to Medical RecordsPresbyterian has adopted the following medicalrecord access standards from Title 8 and Title 13 ofthe NMAC, the Medicare Managed Care Manual,and the HIPAA Standards for Privacy of IndividuallyIdentifiable Health Information. Providers agree tocomply with the following:The primary care practitioner must maintain aprimary medical record for each member thatcontains sufficient medical information from allproviders involved in the member’s care toensure continuity of care.All providers involved in the member’s careshall have access to the member’s primarymedical record.Providers shall request information from othertreating practitioners, with a signed consentfrom the member, as necessary to ensurecontinuity of care.Medical records shall be available to providersfor each clinical encounter. Each specialtycare practitioner shall forward a record to themember’s primary care practitioner of theservices provided.Providers shall ensure the confidential transfer ofmedical, dental, or behavioral health information toanother primary medical, dental, or behavioralhealth provider when a primary medical, dental, orbehavioral health practitioner leaves Presbyterian6-202014 Practitioner and Provider Manual - Ver. 3