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MA PAP209

Medical Record Standards


Provider Administrative Policy

Section
Provider Information
Policy Date
April 2007
Status/Date
Reviewed/February 2013

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Medical Record Standards

Providers are required to maintain a medical record system that conforms to professional medical practice, facilitates audits and claim reviews, and ensures appropriate follow-up treatment. The minimum standards are as follows:

  • Every page in the record contains the member`s name or identification number.
  • The record includes the member`s address, employer, home and work telephone numbers and marital status.
  • The record is legible to a physician reviewer.
  • Significant medical conditions are indicated on the problem list.
  • The record includes treatment and action plans that are consistent with findings.
  • The record includes a health maintenance plan.
  • Medication allergies and adverse reactions are prominently noted.
  • For adults, medical history, including serious accidents, illnesses and surgeries are recorded.
  • For children, medical history, including prenatal care, birth, childhood illnesses and surgeries are recorded.
  • The record includes notes about substance abuse and use of tobacco and alcohol.
  • The record contains subjective and objective information about complaints.
  • The record includes lab work and other studies that have been ordered as appropriate.
  • Working diagnoses are consistent with findings.
  • The record notes any follow-up care needed, including when follow-up is due.
  • Unresolved problems from previous visits are addressed in subsequent visits.
  • If a referral is made for consultation, a note from the consultant is included in the record.
  • Consultation, lab and x-ray reports included in the record are initialed by the PCP, or some other means is used to indicate that they have been reviewed.
  • The record contains evidence that appropriate immunizations, screenings and counseling have been provided in accordance with preventive health guidelines.
  • Each entry is dated, legibly signed or typed and initialed by the service provider.
  • The record includes identification of all providers participating in the member’s care and information on services furnished.
  • The record includes prescribed medications, including dosages and dates of initial or refill prescriptions.
  • The record includes information and documentation in a prominent place that the individual has executed an Advance Directive.
  • The record includes physical examinations, treatment necessary and possible risk factors for the member relevant to the particular treatment.

All medical records should be kept for at least 10 years after the date of the last medical service for which claims have been submitted.


Policy History

Date Action Reason
February 2013 Revised Added language "legibly signed or typed"

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