Medical Records

Patient medical records and health information shall be maintained in accordance with current federal and state regulations (including prior consent when releasing any information contained in the medical record). 

Blue Cross and Blue Shield of Nebraska (BCBSNE) Medicare Advantage providers must maintain timely and accurate medical, financial and administrative records related to services they render to Medicare Advantage members, unless a longer time period is required by applicable statutes or regulations. The provider shall maintain such records and any related contracts for 10 years from date of service. 

The provider shall give without limitation, BCBSNE, U.S. Department of Health and Human Services, U.S. General Accounting Office, or their designees, the right to audit, evaluate and inspect all books, contracts, medical records and patient care documentation, maintained by the provider, which will be consistent with all federal, state and local laws. Such records will be used by Centers of Medicare and Medicaid Services (CMS) and BCBSNE to assess compliance with standards which includes, but not limited to: 

• Complaints from members and/or providers;
• HEDIS^® reviews, quality studies/audits or medical record review audits; 
• CMS and Medicare Advantage reviews of risk adjustment data; 
• BCBSNE Medicare Advantage determinations of whether services are covered under the plan are reasonable and medically necessary and whether the plan was billed correctly for the service; 
• Making advance coverage determinations; 
• Medical Management specific medical record reviews; 
• Suspicion of fraud, waste and/or abuse; 
• Periodic office visits for contracting purposes; and 
• Other reviews deemed appropriate and/or necessary.

Medical record content and requirements for all practitioners (for behavioral health practitioners see below) include, but may not be limited to: 

• Clinical record 
  • Patient name, identification number (name and ID number must be on each page), address, date of birth or age, sex, marital status, home and work telephone numbers, emergency contact telephone number, guardianship information (if relevant), signed informed consent for immunization or invasive procedures, documentation of discussion regarding advance directives (18 and older) and a copy of the advance directives. 
• Medical documentation. 
  • History and physical, allergies, adverse reactions, problem list, medications, documentation of clinical findings evaluation for each visit, preventive services and other risk screening. 
  • Documentation of the offering or performance of a health maintenance exam within the first 12 months of membership. The exam includes: 
    • Past medical, surgical and behavioral history, if applicable, chronic conditions, family history, medications, allergies, immunizations, social history, baseline physical assessment, age and sex specific risk screening exam, relevant review of systems including depression and alcohol screening. 
  • Documentation of patient education (age and condition specific), if applicable: injury prevention, appropriate dietary instructions, lifestyle factors and self-exams. 
• Clinical record — progress notes 
  • Identification of all providers participating in the member’s care and information on services furnished by these providers. 
  • Reason for visit, or chief complaint, documentation of clinical findings and evaluation for each visit, diagnosis, treatment/diagnostic tests/referrals, specific follow-up plans, follow-up plans from previous visits have been addressed and follow-up report to referring practitioner (if applicable). 
• Clinical record — reports content (all reviewed, signed, and dated within 30 days of service or event) 
  • Lab, X-ray, referrals, consultations, discharge summaries, consultations and summary reports from health care delivery organizations, such as skilled nursing facilities, home health care, free-standing surgical centers and urgent care centers. 

For behavioral health practitioners:

• Chief complaint, review of systems and complete history of present illness 
• Past psychiatric history 
• Social history 
• Substance use history 
• Family psychiatric history 
• Past medical history 
• A medication list including dosages of each prescription, the dates of the initial prescription and refills. 
• At least one complete mental status examination, usually done at the time of initial evaluation and containing each of the items below:  
  • Description of speech 
  • Description of thought processes 
  • Description of associations (such as loose, tangential, circumstantial, or intact) 
  • Description of abnormal or psychotic thoughts 
  • Description of the patient’s judgment 
• Complete mental status examination 
• Subsequent mental status examinations are documented at each visit and contain a description of orientation, speech, thought process, thought content (including any thoughts of harm), mood, affect and other information relevant to the case. 
• A DSM-IV diagnosis, consistent with the presenting problems, history, mental status examination and other assessment data.