The following text outlines the legal agreement between the Practitioner and EmblemHealth with regards to the above information.
The term "Practitioner" hereunder shall refer to any contracted primary care physician, specialist, hospital facility and physician practicing within a physicians' group or hospital facility, unless otherwise noted.
Records and Reports
Practitioner shall document all Covered Services provided to Members in a format which is easily retrievable and which conforms with federal, state and local laws and regulations applicable to medical records. Practitioner shall permit the Plan's representative(s) access on-site at Practitioner's practice, upon reasonable prior notice and during regular business hours, to inspect and copy all medical, billing, and financial and statistical records relating to the provision of Covered Services to Members in accordance with all applicable laws and regulations and usual policies and procedures for the maintenance of such records.
Practitioner shall make Members' medical records available to the Plan or its designated representative(s) for, among other purposes, conducting utilization review and assessing quality of care and the Medical Necessity and appropriateness of care provided to Members. Practitioner shall comply with all federal, state and local laws and regulations applicable to the confidentiality, privacy, and maintenance of patient records, including requirements for maintaining such records for six (6) years (10 years for Medicare members) from the last date of treatment or, in the case of a minor, for six (6) years after the minor reaches the age of majority, or for such period of time as required by law, whichever is longer. Record maintenance and audit access shall survive the termination of this Agreement regardless of the cause giving rise to such termination.
Practitioner shall, no later than ten (10) business days after receipt of written request, provide a copy of a Member's medical records, encounter data or financial and statistical records relating to services rendered to Members to the Plan, NYSDOH, and to any other federal, state or local governmental agency, e.g., CMS or LDSS (for Medicaid only), involved in assessing the quality of care or investigating Member grievances or complaints, including the Comptroller General of the State of New York, the Department of Health and Human Services and the Comptroller General of the United States and their authorized representatives. Upon such request from any federal, state, or local government, Practitioner shall provide written notice of such request to the Plan within four (4) business days of such request. All requests for records shall be supplied to the Plan at Practitioner's expense. This provision shall survive termination of this Agreement regardless of the cause giving rise to such termination.
In the event that a Member transfers to another Participating Provider, Practitioner shall, within ten (10) days of a Member's authorization, provide a copy of the Member's medical records to the Member's new Participating Provider without charge. Moreover, Members shall be provided with a copy of their medical records, upon appropriate request, without charge from Practitioner. This procedure will ensure that the new PCP will have a continuous medical record of the member and that there should not be a lapse in continuity or treatment.
Non-Emergent Medical Record Transfer
Upon any change of PCP, the member should be asked to sign a Request for Medical Information. Dates of treatment would be inclusive of current and outstanding laboratory and/or x-ray reports. The Request for Medical Information will be sent to the previous PCP, and the copy of records will be forwarded to the new PCP's office as soon as possible.
Emergent Medical Record Transfer
In the event of a change in PCP in an emergency situation, the Plan may call the previous PCP office directly and request, by phone, that a copy of the medical records be forwarded to the new PCP. A written request would follow by mail within 24 hours of the initial phone contact.
Practitioner shall maintain and provide any other records the Plan may request for regulatory compliance or program management purposes and shall cooperate with the Plan in all fiscal and medical audits, site inspections, peer review, Utilization Management, credentialing and recredentialing and any other monitoring required by federal, state or local regulatory or accreditation agencies, including Utilization Review Accreditation Commission ("URAC") and the National Committee for Quality Assurance ("NCQA"). Any record required by a regulatory or accreditation agency shall, at Practitioner's expense, be delivered to the Plan within the time frame requested by the requesting agency, but in no event more than four (4) business days of its request. Practitioner shall promptly comply with all directives and recommendations issued as a result of any such inspection or audit. Practitioner shall retain all financial and administrative records relating to this Agreement for seven (7) years after the termination of this Agreement, or for such period of time as required by law, whichever is longer. This provision shall survive termination of this Agreement regardless of the cause giving rise to such termination.
Providing Access to Medical Records
Within ten days of a written request, a health care provider must provide an opportunity, for an individual to inspect any patient information (in the provider's possession) relating to the examination or treatment of an individual. The request may come from any qualified person. A "qualified person" means any properly identified subject, or an appointed guardian under article 81 of the mental hygiene law, a parent of an infant, a guardian of an infant appointed pursuant to article 17 of the surrogate's court procedure act (or other legally appointed guardian of an infant who may be entitled to request access to a clinical record) or an attorney representing or acting on behalf of the individual or the individual's estate.
A parent or guardian is not entitled to inspect or make copies of any patient information concerning the care and treatment of an infant where the health care provider determines that access to the information requested by the parent or guardian would have a detrimental effect on the provider's professional relationship with the infant, or on the care and treatment of the infant, or on the infant's relationship with his or her parents or guardian.
Note that a provider may refuse to provide access to information if the provider believes that (i) "review of the requested information can reasonably be expected to cause substantial and identifiable harm to the subject or others which would outweigh the qualified person's right to access to the information, or (ii) the material requested is personal notes and observations, or the information requested would have a detrimental effect as defined by law".
Providers should be familiar with Public Health Law sections 17 and 18 which further define when providers must provide access, timeframes, frequency, when charges may be imposed, etc.