Medi-Cal and Cal MediConnect Medical Records Reviews
- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
Health Net's Facility Site Review (FSR) Compliance Department (Cal MediConnect, Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, Stanislaus, San Diego, and Tulare) conducts periodic medical record reviews (MRRs) to measure provider compliance with current Department of Health Care Services (DHCS) medical record documentation standards. The Medi-Cal/Cal MediConnect Facility Site Review Tool (PDF), Medi-Cal/Cal MediConnect Facility Site Review Guidelines (PDF), Facility Site Review Preaudit Checklist (Health Net Medi-Cal (PDF) or CalViva Health (PDF)), the Medi-Cal/Cal MediConnect Medical Record Review Tool (PDF), and the Medi-Cal/Cal MediConnect Medical Record Review Guidelines (PDF) are available for reference to assist providers in understanding and complying with the required documentation standards.
In an effort to decrease duplicate MRRs and minimize the disruption of member care at provider offices, Health Net and all other managed care health plans are required to collaborate in conducting MRRs. On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a primary care physician (PCP) and administering a corrective action plan (CAP) when necessary. The responsible plan shares the audit results and CAP with the other participating health plans. DHCS reviews the results of MRRs and may also audit a random sample of provider offices to ensure they meet DHCS standards.
Health Net and all other managed care health plans are required to collaborate in conducting medical record reviews (MRRs). On a county-by-county basis, the plans cooperatively determine which plan is responsible for performing a single audit of a primary care physician (PCP) site. The collaborative effort serves to reduce the frequency of audits of the PCP's office by eliminating unnecessary duplication by multiple plans.
Representatives from the responsible plan contact the provider office prior to the MRR to discuss audit policies and procedures. A packet containing documentation materials is sent to the provider prior to the site review to enable the office to prepare for the audit. Copies of the MRR tool and related regulatory requirements are available at The Department of Healthcare Services (PDF).
Written results are provided to the provider at the close of audit by the health plan. Health Net's State Health Programs Quality Improvement Department (Cal MediConnect, Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, Stanislaus, San Diego, and Tulare) is responsible for conducting collaborative reviews on behalf of Health Net.
MRRs of new providers are conducted within 90 calendar days from the date members are first assigned to the provider. An extension of an additional 90 calendar days may be granted if the provider has fewer than 10 assigned members.
A passing score for the MRR is 90%. Providers receiving scores between 80 and 89% (considered a conditional pass) on an MRR audit are required to complete a corrective action plan (CAP). Providers may be re-reviewed in 12 months, or sooner, if deemed appropriate, to assess compliance with the CAP. New members are not assigned to PCPs who receive a non-passing score (below 80%) until all corrections are verified and the CAP is closed.
After the initial audit, participating providers are re-audited at least every three years. A full-scope site audit, which includes both the MRR and Facility Site Review (FSR), is conducted at this time. Providers must receive a conditional passing score of at least 80% on both reviews. Medical record review audit results are shared among Medi-Cal and Cal MediConnect managed care plans. Sites receiving a non-passing score from one plan are considered to have a non-passing score by all other Medi-Cal managed care plans. New members are not assigned to a PCP who receives a non-passing score (below 80%) until all corrections are verified and the CAP is closed. Providers who do not comply with the CAP within the established time frames are removed from the network.
Practitioners who do not comply with a CAP or fail to achieve threshold scores in an audit are forwarded to Health Net's Credentialing Committee for administrative termination. The termination is applicable to the Medi-Cal and Cal MediConnect contracting lines of business and practice locations and remains in effect for three years from the date of the committee's final decision.
The affected practitioner is afforded rights to an informal appeal (reconsideration) of the committee's decision to administratively terminate. The reconsideration shall be administered in accordance with Health Net's Medi-Cal Termination Appeals Process Policy and Procedure.