CurrentsanfranciscohealthplanPolicy ALL PLAN LETTER 22-017
Primary Care Provider Site Reviews: Facility Site Review and Medical Record Review
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Governs DHCS requirements for Medi-Cal managed care plans to perform Facility Site Reviews (FSR) and Medical Record Reviews (MRR) of contracted primary care provider (PCP) sites, including initial and subsequent reviews, certification, scoring, and related processes; affects Medi-Cal MCPs and contracted PCP sites in California.
Policy Summary
Payersanfranciscohealthplan
PolicyPrimary Care Provider Site Reviews: Facility Site Review and Medical Record Review
Policy CodePolicy ALL PLAN LETTER 22-017
Change TypeNo material clinical or coverage changes
Effective DateJul 1, 2022
Next Review Date
Key ActionDo not add PCPs or assign Members until the PCP site has passed an initial FSR and closed required CAPs.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3 yearssubsequent review frequency
10standard MRR records
30 daysCAP primary timeline
3 failsremoval trigger
10 business daysDHCS notification
Facility Site Review (FSR) and Medical Record Review (MRR) Criteria
FSR and MRR operational criteria and rules
Site review requirements, timing, and scoring rules.
Initial site review must include both a Facility Site Review (FSR) and a Medical Record Review (MRR); the FSR is conducted first and must be passed (and any CAPs closed) before adding the PCP to the MCP network or assigning Members.
Initial MRR must be completed within 90 calendar days of the date the MCP first assigns Members to the PCP; MCPs may defer an additional 90 days only if there are insufficient medical records to meet the minimum sample; if fewer than the minimum are available after 180 days, complete the MRR on available records and adjust scoring accordingly.
Subsequent site reviews (FSR and MRR) must be conducted at least every three years after the initial FSR; MCPs may perform reviews more frequently per county collaboration or monitoring needs.
Scoring: FSR elements include Critical Elements (CE) weighted 2 points and non-critical elements weighted 1 point; all MRR elements are weighted 1 point; scores must be based on documented evidence, demonstrations, and interviews; MCPs must not alter tool criteria or assigned weights.
MRR standard sample: 10 randomly selected medical records per Provider (pediatric, adult, or obstetric as applicable); for shared medical record practices, sample size increases with number of PCPs: 1-3 PCPs = 10 records; 4-6 PCPs = 20 records; 7+ PCPs = 30 records; if minimum records not available, document rationale and adjust scoring.
Supplemental facilities (mobile, satellite, school-based, etc.) require initial and subsequent reviews at least every three years, with focus appropriate to services provided and oversight coordinated by the MCP and county collaborators.
DHCS oversight: DHCS may conduct independent FSRs and MRRs to validate MCP processes and will notify MCPs of updates to tools/standards; MCPs must use current DHCS FSR and MRR tools and standards when conducting reviews.
Certificates: MCPs must not add PCPs or assign Members until the PCP site has a passing FSR and completed CAPs; a DHCS Site ID must be assigned to each PCP site reviewed.
CAPs, Monitoring, Scoring and Reviewer Certification
Corrective Action Plans (CAPs), monitoring, scoring, and reviewer certification requirements.
A CAP is required for all cited deficiencies for PCP sites that have a conditional pass or non-passing FSR and/or MRR, and MCPs may require CAPs for other findings that need correction; CAPs are also required for CE, pharmacy, and infection control deficiencies regardless of overall score.
Day-of-review initiation: On the day of the FSR/MRR, MCPs must provide verbal notification of CE findings with signed attestation and provide a written CAP request and scores within one business day.
CAP timelines and actions: PCP must submit CAPs and evidence per the established timeline; MCPs must verify CE completion within 30 calendar days (extensions up to 60 days may be granted at MCP discretion); non-CE CAPs must be submitted and verified within the timelines (MCP verifies/approves within 60 days and all non-critical CAPs closed within 90 days; extensions up to 120 days may be requested from DHCS under extenuating circumstances).
Verification and closure: MCPs are responsible for follow-up, verification, and closure of CAPs; verifications may be via document review (fax/email), virtual platform, or onsite review per nurse reviewer discretion; DHCS may require onsite verification and closed CAP documentation must include evidence of corrections, dates, MCP reviewer name/title, and resources provided.
Assignment and removal rules
- MCPs must not assign new Members to PCP sites with failing scores or open CAPs until deficiencies are corrected and CAPs are closed.
- If a PCP site fails on three consecutive FSRs or MRRs, the provider must be removed from the MCP network without further CAP opportunity and other MCPs must also remove the PCP; MCPs must reassign Members expeditiously.
Monitoring: MCPs must monitor all PCP sites between scheduled reviews, at minimum monitoring all Critical Elements; deficiencies identified during monitoring may prompt focused or full site reviews.
Shared medical records sampling: For shared medical record practices, MCPs must use the increased sample sizes by number of PCPs (1-3 = 10; 4-6 = 20; 7+ = 30) when developing CAPs and scoring; if additional records are reviewed, scores must be calculated accordingly.
Scoring weights: All MRR elements are weighted one point; FSR non-critical elements weighted one point; Critical Elements weighted two points; there is no rescoring when deficiencies are corrected at the time of audit and points remain deducted.
Reviewer certification and personnel: MCPs must designate and maintain certified site reviewers (CSRs) and Certification Maintenance Trainers (CMTs) per DHCS requirements; candidates must meet licensure/employment requirements, complete inter-rater processes, and meet specified inter-rater variance thresholds; recertification occurs per DHCS schedule.
Inter-rater and certification procedures: CMT and CSR candidates must complete the inter-rater review process; failing inter-rater allows one repeat attempt, and a second failure requires waiting six months before reapplying; CMTs/CSRs must complete minimum review counts post-certification and attend periodic DHCS workshops as required.
Data and documentation retention: MCPs must maintain certification records, training activities, CAP documentation, and supporting materials for site reviewers as required by DHCS.
MCP operational and compliance criteria for site reviews
Operational and compliance requirements MCPs must follow for site review data submission, DHCS interactions, and reviewer management.
Data submission: MCPs must submit site review data to DHCS every six months (Jan–Jun due July 31; Jul–Dec due January 31) in the approved format uploaded to the DHCS secure site; preoperational/expansion site review data must be submitted at least six weeks prior to operation and DHCS may reject nonconforming formats.
PHI handling: MCPs must collect Protected Health Information (PHI) as part of MRRs and include PHI in the bi-annual submissions to DHCS; virtual reviews and data transmissions must comply with HIPAA.
DHCS-conducted reviews and notifications: DHCS conducts site reviews to validate MCP processes, notifies MCPs of critical findings in writing within 10 business days, and provides a full written report within 30 calendar days; MCPs must submit a CAP to DHCS within 30 calendar days responding to all cited deficiencies in DHCS reports.
Policy and P&P updates: If this APL requires MCP policy and procedure changes, MCPs must submit updated P&Ps to their MCOD contract manager within 90 days; if no changes needed, MCPs must submit an email confirmation within 90 days stating P&Ps reviewed and unchanged (include APL title and release date in subject line).
Notification responsibilities: DHCS will notify MCPs approximately four weeks prior to DHCS-conducted site reviews; MCPs must notify their Providers in advance of site reviews, although certain inspections or surveys may be conducted without prior notice.
MCP oversight obligations: MCPs are responsible for ensuring subcontractors and network providers comply with applicable laws, contract requirements, and DHCS guidance (including APLs); MCPs must communicate these requirements to subcontractors and network providers.
Certification and recertification obligations: MCPs must maintain CMT and CSR certification records, ensure reviewers meet inter-rater variance thresholds, complete minimum required site reviews post-certification, and participate in required trainings and statewide reviewer activities per DHCS requirements.
Scoring, Sample Sizes, and Code Tables
FSR scoring elementsmixed
| CE | Critical Elements — weighted 2 points |
| NCE | Non-critical Elements — weighted 1 point |
FSR Element Typesmixed
| CE | Critical Element (FSR element weighted 2 points; largest potential for adverse patient effects) |
Not applicablemixed
| No billing or CPT/ICD codes specified in this portion of the document. |
inv-07: MRR sample size
Standard sample size10 medical records per PCP (standard MRR sample)
Shared medical records: 1-3 PCPsReview minimum 10 medical records
Shared medical records: 4-6 PCPsReview minimum 20 medical records
Shared medical records: 7+ PCPsReview minimum 30 medical records
inv-08: FSR scoring pass thresholds
Exempted Pass (FSR)Score ≥90% with no deficiencies in Critical Elements, infection control, or pharmacy — CAP not required
Conditional Pass (FSR)Score 80–89% — CAP required
Fail (FSR)Score ≤79% — CAP required
inv-09: MRR scoring thresholds
Exempted Pass (MRR)All section scores ≥80% — CAP not required
Conditional Pass (MRR)Overall 80–89% or one or more sections <80% — CAP required
Fail (MRR)Score below thresholds (per tool) — CAP required
inv-10: Inter-rater variance thresholds
CMT/CSR inter-rater variance (FSR & MRR)Achieve inter-rater scores within 10% for FSR and 10% for MRR with designated CMT/CSR
MRR statewide variance for CMTAchieve within 5% variance on the statewide MRR inter-rater score as defined by SRWG and DHCS
MRR statewide variance for CSRAchieve within 10% variance on the statewide MRR inter-rater score as defined by SRWG and DHCS
Network Enrollment, Notifications, CAPs, and Reviewer Requirements
Note
Network enrollment and certification requirements
MCPs must not add PCPs to their Network or assign Members to Providers until the PCP site has received a passing FSR score and completed all CAPs; MCPs must issue a dated Certificate of Completion after the site successfully completes both the FSR and MRR and closes all CAPs (Certificate valid up to three years). DHCS Site ID must be assigned by designated MCPs to each PCP site reviewed.
- Do not add or assign Members until passing FSR and CAP closure.
- Issue a dated Certificate of Completion after passing both FSR and MRR and closing CAPs (valid up to 3 years).
- Assign a DHCS Site ID to each PCP site as required.
Note
Notification and unannounced inspections
MCPs must notify Providers in advance of scheduled site reviews; however, inspections or elements of reviews may be conducted without prior notice, including unannounced inspections or inspections in conjunction with other medical surveys.
- Provide advance notification to Providers for scheduled site reviews.
- Be prepared for inspections or review elements that may occur without prior notice.
Denial Risk
Notification and Network Actions
When a PCP site receives a failing FSR or MRR score, the MCP must notify the PCP site of the score, all cited deficiencies, and CAP requirements; MCPs may remove a failing PCP site from their network and must not assign new Members to sites with failing scores until the CAP is verified closed.
- Notify PCP site of failing score, cited deficiencies, and CAP requirements.
- MCP may remove failing PCP site from Network; if retained, require and verify corrections per CAP timelines.
- Do not assign new Members to PCP sites with failing scores until deficiencies are corrected and CAP closed.
Documentation Required
CAP Initiation Requirements
On the day of the FSR and/or MRR the MCP must provide verbal notification of any Critical Element (CE) findings with a signed attestation, provide a formal written request for CAPs and the FSR/MRR scores no later than one business day after the visit, and within 10 business days require the PCP site to submit CAPs and evidence for CE findings; the MCP must provide the CAP template, instructions, and educational support.
- Provide verbal CE notification and obtain signed attestation (starts CE-CAP timeline).
- Deliver formal written CAP request and FSR/MRR scores no later than one business day after visit.
- Provide CAP template, due dates, corrective actions, submission instructions, and MCP contact information.
- Within 10 business days, require PCP to submit CAP and evidence for CE findings; MCP to review and approve or request more information.
Documentation Required
Site reviewer certification and recertification responsibilities
Site reviewers must possess and maintain required certifications: maintain CMT certification, complete a minimum of 30 site reviews following initial certification or recertification, attend DHCS-sponsored inter-rater workshops every three years, and meet the specified inter-rater variance criteria.
- Maintain CMT certification and participate in DHCS-sponsored trainings and SRWG activities.
- Complete at least 30 site reviews after certification or recertification.
- Attend DHCS inter-rater workshops in person or virtually every three years.
- Achieve required inter-rater variance thresholds as specified for CMT/CSR roles.
Documentation Required
Personnel qualifications for CSRs and CMTs
CSRs and CMTs must possess a current, valid California license (RN, MD, DO, NP, or PA) and be employed by or subcontracted with an MCP to serve as a CSR or CMT.
- Hold a current and valid California RN, MD, DO, NP, or PA license.
- Be employed by or subcontracted with an MCP to perform CSR or CMT duties.
Prior Authorization
Corrective Action Plan submission
MCPs must submit Corrective Action Plans (CAPs) to DHCS within 30 calendar days of receipt of a DHCS-conducted site review report that address all cited deficiencies and, for long-term corrective actions, include initiation of remedial actions, a plan to achieve compliance, and documentation of when full compliance will be achieved.
- Submit CAP to DHCS within 30 calendar days of receipt of DHCS site review report.
- Include identified deficiencies and actions taken to correct them.
- If long-term remediation is required, include initiation actions, a remediation plan, and dates for achieving full compliance.
- Provide additional supporting documentation if DHCS determines the CAP is insufficient.
Key Terms and Definitions
inv-18: Any facility in which primary care services are provided to Members.
DefinitionAny facility in which primary care services are provided to Members.
ScopeIncludes all locations required to support safe and effective provision of primary care as part of MCP oversight obligations.
PurposeUsed as the unit of review for FSR and MRR processes.
inv-19: A unique identifier assigned by designated MCPs to each PCP site reviewed; new ID or modifier assigned on ownership change.
DHCS Site IDA unique identifier assigned by designated MCPs to each PCP site reviewed; new ID or modifier assigned on ownership change.
AssignmentDHCS releases sets of Site ID numbers by county; MCPs assign IDs for reviewed sites.
Ownership changeNew DHCS Site ID will be assigned or existing ID modified to represent ownership change.
inv-20: Mobile, satellite, school-based, and other extension clinics that provide primary care services as extensions of PCP sites or standalone clinics.
Supplemental facilities - definitionMobile, satellite, school-based, and other extension clinics that provide primary care services as extensions of PCP sites or standalone clinics.
ServicesMay offer preventive care, immunizations, screenings, and chronic care management (excluding specialty services).
Review frequencyInitial site review and subsequent reviews at least every three years, focused on services provided.
inv-21: When multiple PCPs use the same medical records for documentation of patient care; MCPs must review records proportional to number of PCPs.
Shared medical record practice - definitionWhen multiple PCPs see the same patients and use the same medical records for documentation of patient care.
Sampling ruleMCP must review number of records proportional to number of PCPs in the shared record system (see MRR sample size).
If records not identifiableConsidered shared; adjust sampling and document rationale if minimum records unavailable.
inv-22: Shared Medical Records Practice
DefinitionShared Medical Records Practice: multiple PCPs see same patients and use same medical records; records not identifiable as belonging to a specific PCP.
ImplicationMCPs must increase MRR sample size per number of PCPs (10/20/30) and may request additional records as needed.
Virtual reviewsBoth onsite and virtual MRRs may include review of shared records and must comply with HIPAA.
inv-23: Critical Element (CE)
Critical Element (CE) - definitionFSR elements indicated by bold/underlined text with greatest potential for adverse effects on patient health or safety; weighted two points.
WeightingCEs = 2 points; non-critical elements = 1 point for FSR; all MRR elements = 1 point each.
Role in scoringCE deficiencies may trigger CAP requirements regardless of overall score depending on infection control or pharmacy findings.
inv-24: Focused Review
Focused Review - definitionA targeted review of one or more specific areas of the FSR or MRR used for monitoring or follow-up; cannot substitute for a full site review.
Use casesUsed for monitoring between full site reviews, investigating monitoring-identified problems, or following up on corrective actions.
CAPsDeficiencies found in a focused review that require CAPs must follow standard CAP timelines and verification procedures.
inv-25: CMT (Certification Maintenance Trainer) and CSR (Certified Site Reviewer) roles and associated requirements
RolesCMT (Certification Maintenance Trainer) and CSR (Certified Site Reviewer) — designated site reviewer roles with certification requirements.
Licensure & employmentMust possess a current valid California license (RN, MD, DO, NP, or PA) and be employed by or subcontracted with an MCP.
Training & recertificationMaintain CMT certification, participate in DHCS trainings/SRWG, attend inter-rater workshops every three years, and complete minimum site review counts.
Inter-rater expectationsComplete inter-rater review process and meet specified inter-rater variance thresholds; remediation rules apply for failures.
inv-26: MRR data and PHI submission
PHI collectionMCPs must collect PHI as part of the MRR process and include PHI in the bi-annual data submission to DHCS.
Bi-annual submissionSubmit site review data to DHCS every six months (Jan–Jun due July 31; Jul–Dec due Jan 31) in approved format.
Secure uploadData must be uploaded to a designated DHCS secure site; DHCS may reject nonconforming formats.
Policy Summary
Payersanfranciscohealthplan
PolicyPrimary Care Provider Site Reviews: Facility Site Review and Medical Record Review
Policy CodePolicy ALL PLAN LETTER 22-017
Change TypeNo material clinical or coverage changes
Effective DateJul 1, 2022
Next Review Date
Key ActionDo not add PCPs or assign Members until the PCP site has passed an initial FSR and closed required CAPs.
SourceLink
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