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Keeping Your Patients’ Health in Mind

Our medical record standards and obligations

Horizon BCBSNJ requires medical records to determine whether a member’s condition has been monitored, evaluated, assessed and/or treated at any time during the year. Some quality programs, like Medicare Stars and HEDIS®, require medical records to evaluate a provider’s performance in quality as well as service.

As a participating physician or other health care professional, you must adhere to accepted practices regarding medical record retention. Failure to comply with a request for medical records and or additional documentation can result in termination from our network(s). Medical record requests are a key part of our risk adjustment activities. Medical record reviews help us confirm suspected chronic conditions that haven’t been submitted on a claim for a specific service date range. Conditions that are actively being treated, or those that may affect the patient's treatment, should be reported on a claim at least once every calendar year. These reviews can also help identify patients who may benefit from our care and disease management programs.

In support of these activities, your office may receive medical record requests from our contracted vendor, Inovalon. We thank you for your cooperation with Inovalon by sending records or allowing us to retrieve them from your office.

Your response is required for medical documentation requests

According to your Provider Agreement(s), you agree:

  • That Horizon BCBSNJ and its affiliates and designees have the right to review any and all documents, books and records, including but not limited to medical records, maintained by you in connection with services you provided.
  • To provide copies of these materials, in the manner and within the time frame requested by Horizon BCBSNJ.

Horizon BCBSNJ does not provide reimbursement for medical record copies, postage and/or for any other miscellaneous costs associated with the retrieval of medical records.

Important reminders about medical record requirements

Please keep in mind the following information as you manage and maintain your patients’ medical records.

Records of Medicare Advantage (MA) members

Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years.

Records of all other (non-MA) members

  • Professional providers: Seven years from the date of the most recent entry.
  • Hospital (adult): 10 years following the most recent discharge.
  • Hospital (minor): 10 years following the most recent discharge, or until the patient is age 23 years, whichever is longer.
  • Hospital (all): Discharge summary sheets 20 years after discharge.

All medical records should:

  • Clearly support a face-to-face or telemedicine encounter with the patient.
  • Be complete, precise and reflect the diagnoses, scope of care and services provided.
  • Include encounters completed by an acceptable physician or other health care professional (e.g., physicians, certified physician assistants, nurse practitioners).
  • Be clear and legible, with the patient’s name and date of the encounter appearing on all pages.
  • Resemble the SOAP format: Subjective, Objective, Assessment, Plan.
  • Include the physician or other health care professional’s credentials, with all appropriate signatures.
  • Include the professional’s signature date, which cannot be greater than 30 days from the patient encounter.
  • Contain a signed discharge summary report that includes both an admission and discharge date (for hospital inpatient medical records).

For specific questions, please contact your Provider Educator:

Risk adjustment activities

Risk adjustment is a methodology used to align payments to health plans based on the demographics (e.g., age and gender) and the health status of enrollees. Under the Affordable Care Act (ACA), the submitted diagnosis code(s) are used to calculate a health plan’s level of risk of high-cost enrollees and required payment transfers between health plans.

Horizon BCBSNJ participates in risk adjustment to stabilize premiums and to protect against the negative effects of adverse risk selection for members enrolled in Commercial, Individual and Small Group plans, Medicaid and Medicare Advantage plans.

Published on: November 24, 2020, 09:39 a.m. ET
Last updated on: April 22, 2021, 06:12 a.m. ET