CurrentOscar HealthPolicy HI-001-A11

Medical Record Review Standards for Primary Care Providers

Governs annual medical record reviews of a random sample of contracted primary care providers for Oscar's products in states with medical record regulatory requirements; defines standards, procedures, and responsibilities for maintaining and reviewing medical records and coordination with behavioral health.

Policy Summary

PayerOscar Health

PolicyMedical Record Review Standards for Primary Care Providers

Policy CodePolicy HI-001-A11

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionMedical record reviews are performed annually in Q4 on a random percentage of contracted PCPs and PCPs not meeting standards will be issued corrective action plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

annualfrequency of medical record reviews

10 yearsrecord retention period

random sampleselection method

standardizedwellness screening form

80%compliance threshold

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Medical Record Review — Criteria

inv-01: Medical record documentation criteria

Medical records will be evaluated against the following documentation criteria during reviews.

Every page contains patient name or ID number

Allergies or No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location

All presenting symptom entries are legible, signed, and dated, including phone entries

Dictated notes are signed or initialed; if initialed a signature sheet is available

Important diagnoses are summarized and highlighted

Problem list is maintained and updated for significant illnesses and medical conditions

Medication list or reasonable substitute is maintained and updated for chronic and ongoing medications

History and physical exam identify appropriate subjective and objective information pertinent to the presenting symptoms, and the treatment plan is consistent with findings

Past medical history is documented including significant illnesses, accidents, operations, and (for pediatric members) prenatal and birth information

Each visit notation includes subjective data (chief complaint), objective data (focused physical exam), assessment (diagnosis or impression), and plan (treatment plan and goals)

Laboratory tests and other studies are ordered as appropriate with results noted and follow-up recommendations or documentation of non‑compliance to the care plan

Referrals to specialists are clearly documented with evidence of continuity and coordination of care when services were provided elsewhere

Age‑appropriate routine preventive services and refusals are documented

Advance directive documented in the record or evidence it was discussed or declined

Demographic information documented (name, address, phone, preferred language, DOB, disabilities as applicable)

Emergency contact information is noted

There is evidence of annual staff confidentiality training

Medical records are stored securely and access is limited to authorized personnel

inv-02: Clinical documentation criteria

Required clinical documentation elements for each visit include:

Subjective data including chief complaint

Objective data: focused (problem‑specific) physical exam

Assessment: diagnosis or impression

Plan: treatment plan and goals, including timeframes for follow‑up when indicated

Dates of encounters and pertinent information documenting the member's diagnosis(es)

Consultation, laboratory, and imaging reports filed in the chart are initialed or acknowledged by the provider who ordered them to signify review

inv-03: Documentation review and corrective action criteria

Medical record review uses a standardized 28‑item assessment form; results determine compliance and required corrective actions.

Review uses a standardized 28‑item assessment tool covering chart organization, demographics, clinical information, acknowledgements of reports, contacts with family/guardians, continuity and coordination of care, and behavioral health coordination

Total responses across the 28 items are tallied; compliance percentage is calculated as (total yes) / (total yes plus no) x 100

Records scoring greater than 80% are classified as Compliant; records scoring 80% or less are classified as Noncompliant

If records do not meet the 80% compliance standard, the PCP will be issued a Corrective Action Plan (CAP) with objective interventions and target completion dates

Documentation reviewed should include progress notes, discharge summaries, consult reports, therapy and home health reports, acknowledgements of labs/imaging, medication lists, allergies, demographics, and behavioral health coordination as applicable

Documentation Components & Compliance Metrics

Documentation componentsmixed

No codes listed

Documentation compliance threshold

Compliance threshold80% — records scoring >80% are classified as Compliant

Scoring basisCompliance percentage is calculated using total 'yes' responses divided by total 'yes' plus 'no' responses (per Compliance Calculation)

Checklist sizeTotal assessment includes 28 items used to compute the compliance percentage

Provider Responsibilities & Corrective Actions

Note

Medical record review process and corrective action — Annual Q4 random-sample reviews of contracted PCPs in regulated states; describes process and corrective action flow.

Medical record reviews are performed annually in Q4 on a random sample of contracted primary care providers (PCPs) in states with medical record regulatory requirements. For review purposes, PCPs include family medicine, general medicine, internal medicine, pediatrics, and obstetrics/gynecology when acting as a PCP. Reviews assess maintenance and availability of records, documentation standards, and record-keeping practices. When records are obtained through HEDIS, HCC/RAF, peer review, focused QI studies, grievance/appeal reviews, claims reconciliation, or other triggers, the Quality Improvement Coordinators conduct the audits. Office site visits by Network Management or site reviews triggered by complaints also assess record keeping (e.g., secured storage).

Documentation Required

Follow-up documentation — Primary care follow-up timing and documentation expectations (time of return noted in weeks or months when applicable).

Primary care follow-up must be documented when indicated (for example: calls, visits, tests, referrals). Documentation must include the reason for follow-up and the expected time of return expressed in weeks or months when applicable. Follow-up entries should specify whether the follow-up is for routine monitoring, symptom reassessment, test result review, or care coordination, and should reference any outstanding orders or referrals. This information is part of the Documentation Standards and Review Tool for Medical Records and will be evaluated during medical record reviews.

Key Terms & Record Elements

Primary Care Provider (PCP) definition

PCP specialtiesFamily medicine; General medicine; Internal medicine; Pediatrics; Obstetrics/Gynecology when acting as a PCP

Context of definitionUsed for selection of providers for annual medical record reviews in states with medical record regulatory requirements

ApplicabilityDefinition applies to contracted PCPs for Oscar's products

SMI (severe mental illness)

Included conditionsObsessive-Compulsive Disorder; Anorexia Nervosa; Panic Disorder; Bipolar Disorder; Pervasive Developmental Disorder; Bulimia Nervosa; Schizoaffective Disorder; Major Depressive Disorder; Schizophrenia

PurposeReferenced for coordination and evaluation of patients with behavioral health needs within the medical record

Policy Summary

PayerOscar Health

PolicyMedical Record Review Standards for Primary Care Providers

Policy CodePolicy HI-001-A11

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionMedical record reviews are performed annually in Q4 on a random percentage of contracted PCPs and PCPs not meeting standards will be issued corrective action plans.

SourceLink

On This Page

Contacts with the member's family/guardian noted when applicable

Use of a standardized wellness screening form to prompt and track age‑appropriate screening services

Advance directive documented or evidence of discussion/declination noted

Medication allergies/adverse reactions prominently noted (or documented as none)

Medication list present if prescriptions are ordered; past medical history documented

History and physical exam identify appropriate subjective and objective information pertinent to the member

Documentation Required

Report acknowledgement — Consultation, laboratory, and imaging reports must be initialed/acknowledged by ordering provider to signify review.

Consultation, laboratory, and imaging reports filed in the chart must be initialed or otherwise acknowledged by the ordering provider to signify review. This acknowledgment documents that the provider has seen and reviewed results and supports continuity of care and appropriate follow-up planning.

Denial Risk

Corrective Action for Noncompliance — When standards are not met, PCPs will be issued a Corrective Action Plan (CAP) and related steps.

When medical record standards are not met and opportunities for improvement are identified, the PCP will be issued a Corrective Action Plan (CAP) containing objective interventions, measurable expectations, and target completion dates. A CAP is issued when 80% of reviewed records do not meet the individual record compliance standard of 80%. If a provider’s stratified score is >80% they are compliant and no action is required; scores at or below 80% trigger noncompliance procedures, including issuance of a CAP and follow-up monitoring until remediation is verified.

Advance directive

Documentation standardAdvance directive is either present in the medical record or there is evidence it was discussed with or declined by the member

Chart itemAdvance directive is one of the checklist items evaluated on the Documentation Standards and Review Tool

Recording guidanceEvidence of discussion or declination may substitute when the directive itself is not on file

Medication allergies/adverse reactions

Visibility requirementMedication allergies and adverse reactions must be prominently noted in the record (e.g., prominently displayed in EMR such as red font) and documented in the progress note at each new encounter

No known allergiesIf the member has no known allergies or adverse reactions, this must be appropriately noted in the record

Checklist inclusionAllergy documentation is an assessed item on the Documentation Standards and Review Tool

Medication list / Problem list

Medication list presenceA medication list must be present in the chart when prescriptions are ordered

Problem list expectationsSignificant medical conditions/illnesses must be noted on the health problems (problem) list

Past medical historyPast medical history including significant illnesses, accidents, operations, and relevant pediatric prenatal/birth information should be documented

Compliant

Definition of CompliantRecords with a score greater than 80% are labeled 'Compliant' and require no further action

Source of labelStratification described in the Documentation Standards and Review Tool and Stratification of Score guidance

ImplicationCompliant result indicates the record met the overall documentation standard on the 28-item tool

Noncompliant and corrective actions

Definition of NoncompliantRecords with a score of 80% or less are labeled 'Noncompliant'

Corrective action triggeredWhen records are Noncompliant, the PCP will be issued a Corrective Action Plan (CAP) with objective interventions and target completion dates

Threshold applicationA CAP is issued when 80% of reviewed records do not meet the individual record compliance standard of 80%

Review tool basisNoncompliance determination is based on the 28-item Documentation Standards and Review Tool and the compliance calculation formula