The notification of retrospective review sent to the provider will contain a list of specific cases that must be submitted to the review team chosen by a case selection procedure that combines random sampling and cases identified as “high utilization” and “outliers.”
A. High utilizers are beneficiaries with rate of high utilization.
B. Outliers are defined as providers who are providing services in an amount that is over and above the average amount of services being provided by their peers.
The review period will be specified in the provider notification letter. The letter will also state the date by which all records must be received by the contractor.
The list of cases to be reviewed will be sent to the provider with a request for certain components of the records.
The information requested includes:
A. Face Sheet
B. Initial Certification of Need (CON) and all subsequent CON decisions
C. Psychiatric Evaluation and all updates
D. History & Physical and all updates
E. Intake Assessment and all updates
F. Psychosocial Assessment and all updates
G. Nursing Assessment and all updates
H. Psychological Testing
I. Psychosexual Assessment if the beneficiary is in a Sexual Offender Program
J. Treatment Plans: Initial, Master and updates covering the specified period
K. Progress Notes: Nursing, M.D., Therapy, Shift/Milieu for specified period
L. All Physician Orders
M. All Therapeutic Leave of Absence Forms
N. All Special Treatment Procedures Forms
O. Initial and Current PCP Referrals
The contractor has the right to request other parts of the health record or the entire record if needed.