Upcoming Medical Record Review Standards

PA Medicaid and Medicare Assured^®

As part of our contract with the Pennsylvania Department of Human Services (DHS) to provide medical coverage for the Medical Assistance/Medicare population, we are required to perform medical record audits. These reviews are conducted on a periodic basis to ensure that our providers keep accurate and sufficient record documentation on our members.

This review assesses compliance with multiple standards and critical elements developed and approved by the Highmark Wholecare Quality Improvement & Utilization Management Committee to meet state, federal, and regulatory requirements. Some examples of these standards include documentation of continuity and coordination of care, execution of an advanced directive, legibility of written documentation, follow-up visits, and signing/dating of notes.

Records readily available from various projects may be reviewed, and some formal requests for records will be made. If your practice is selected for a formal review, you will be contacted by the Quality Improvement Team for support and guidance. We kindly ask for your assistance with providing copies of the supporting documentation relating to the medical record review standards. For your reference, the Medical Record Review Standards are available upon request, or can be found on our Provider Resource Center (PRC).

Our intention is to provide feedback and work collaboratively to address areas needing improvement. Our goal is to ensure that our members’ medical records meet the required regulatory standards as outlined by contractual agreement.