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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Revised Random Medical Review Process

2010 Revised Random Medical Record Review Process
Our random medical record review (MRR) process has recently undergone some revisions in 2009. This impacted our network primary care providers (PCPs). The goal was to adopt one MRR process across our enterprise. 
Our company has medical record standards that require practitioners to maintain medical records in a manner that is current, organized and facilitates effective and confidential member care and quality review. We perform medical record reviews to assess network PCPs’ compliance with current medical record standards recognized by the National Committee for Quality Assurance (NCQA). All reviews are conducted by a nurse under the supervision of the local Medical Director. 
These MRRs historically have been performed annually on a percentage of randomly chosen PCPs identified through claims and the HEDIS® process (Healthcare Effectiveness Data and Information Set) and contracted with our managed care products. These products include POS, HMO, PPO, State Sponsored Business and Medicare Advantage. Typically, the timeline for this process is June through September annually. In order to pass the review, an office must score 80% or greater. If a practitioner fails to meet the company’s standard of 80%, a re-review is conducted within six months. Our MRR process is currently underway for 2010. Data results from this quality program will be available later this year, for your review. 
MRRs are not required if the PCP’s office has Electronic Medical Records (EMR) or their office has been recognized by the NCQA Physician Practice Connection Program. 
There are two (2) sections on the audit tool: Office Specific Questions (written policies) and Chart Elements/Content and Clinical Documentation (organization of medical records and preventive health service documentation).  
Advance directives reminder: Please remember to include documentation of an advance directive in a prominent part of a Medicare Advantage member’s medical record, and include a copy of the directive in the medical record. For more information on Medical Record Standards, Click here to view our Medical Record Standards.  
Thank you for your assistance with participating in this very important quality initiative these past years. We look forward to working collaboratively with you on other quality programs, such as HEDIS®. 
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.