Medical Record Audits

EmblemHealth’s Quality Management department is required to conduct several medical record audits each year for regulatory reporting and quality assurance purposes. The medical audit field team consists of nurses and non-clinical support. When on site, the team will answer any questions you may have.

If you are contacted to supply medical records for these audits, you are encouraged to respond as expeditiously as possible. Rest assured that in supplying the requested records to EmblemHealth, you are in no way violating any HIPAA privacy rules.

Schedule of Medical Record Audits

January - December: Communicable Disease Record Audit 
March - May: HEDIS/QARR Medical Record Review 
August - September: Quality Medical Record Audit 
October - December: DOH Article 44 Prenatal Audit

January - December: DOH Communicable Disease Record Audit

The DOH Communicable Disease audit evaluates the compliance of practitioners in following the DOH guidelines for notifying a positive result of a communicable disease.

March - May: HEDIS/QARR Medical Record Review

The HEDIS (Healthcare Effectiveness Data and Information Set)/QARR (Quality Assurance Reporting Requirement) audit involves the following measures:

• Childhood immunization and lead testing
• Immunization for adolescents
• Cervical cancer screening
• Care of the older adult
• Medication reconciliation post discharge
• Well child visits in the first 15 months of life
• Well child visits in the 3rd, 4th, 5th and 6th years of life
• Adolescent well care
• Comprehensive diabetes care
• Prenatal and postpartum care
• Frequency of ongoing prenatal care
• Cholesterol management for patients with cardiovascular conditions
• Controlling high blood pressure
• Colorectal cancer screening
• Adult BMI assessment
• Weight assessment and counseling for nutrition and physical activity

For additional information and a complete outline of the above measures, please go to www.ncqa.org.

August - September: Quality Medical Record Audit

The Quality Medical Record Audit follows EmblemHealth’s medical record documentation guidelines and may involve disease-specific guidelines and HEDIS measures.

October - December: DOH Article 44 Prenatal Audit

The DOH Article 44 Medical Record Audit evaluates:

• The overall quality of care members are receiving and, with respect to pregnant members, the number of prenatal visits and evidence of a postpartum visit within 56 days of delivery
• Documentation in the member’s medical record of HIV/AIDS testing and pre- and post-test counseling
• Referral of high risk pregnancies to HIP or delegate case management services
• Documentation of a WIC referral