Attention Behavioral Health Providers:

Anthem's Medical Record/Chart Review Program for Health Plans Purchased on or off the Health Insurance Marketplace -- FAQs

 

Purpose

Anthem has been working with Inovalon – a vendor – to implement a medical record/chart review program for those members who have purchased our individual and/or small group health plans on or off the Health Insurance Marketplace (often referred to as the exchange).

The purpose of this document is to address some frequently asked questions (FAQs) regarding our recent requests for copies of medical records/charts for some of your patients – previously sent by Inovalon on Anthem's behalf. We hope you find this document helpful.

General Questions

1. Why is Anthem requesting records for Exchange members?

Each year, Anthem requests your assistance in our retrospective medical chart review programs. We continue to request members' medical records to obtain information required by the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Centers for Medicare & Medicaid Services (CMS). In 2014, we began requesting medical records/charts for members who have purchased our individual and/or small group health plans on or off the Exchange as well. This particular effort is part of our compliance with provisions of the Affordable Care Act that require our company to collect and report diagnosis code data that may have not been previously documented for our members who have purchased individual or small group health plans on or off the Exchange. Our company has engaged Inovalon to contact providers on our behalf to collect and review medical record/chart information.

2. I am a behavioral health provider. Is Anthem requesting that I provide "psychotherapy notes" as part of the medical record request?

No. Anthem is NOT requesting "psychotherapy notes." Under the Health Insurance Portability and Accountability Act (HIPAA), psychotherapy notes are defined as "notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the individual's medical record." (45 CFR 164.501)

Psychotherapy notes do NOT include:

  • Medication prescription and monitoring
  • Counseling session start and stop times
  • Modalities and frequencies of treatment furnished
  • Results of clinical tests; and
  • Summary of the following:
    • Diagnosis
    • Functional status
    • Treatment plan
    • Symptoms
    • Prognosis; and
    • Progress to date

As a result, we are permitted to collect the above information to support our review, and you should provide, where applicable, pursuant to the record request.

3. What if "psychotherapy notes" are included in combined medical record?

If the medical documentation includes any of the information included in the definition of psychotherapy notes in §164.501, the provider is responsible for excluding or removing the information from their submission.

4. Certain state laws prohibit the disclosure of a patient's behavioral health medical information without a proper consent or authorization obtained from the behavioral health patient.

Anthem does not collect such an authorization at enrollment, nor would such an authorization cover disclosures made by behavioral health providers to Anthem. As such, Anthem assumes that any behavioral health record being sent to comply with the Affordable Care Act's Risk Adjustment provisions is being sent pursuant to a consent or authorization obtained by the treating provider in accordance with state law. As this activity relates to health plan operations, an authorization or consent obtained from the patient at the point of service should be sufficient to cover this disclosure.

5. California law requires that any information related to outpatient psychotherapy provided by a licensed outpatient psychotherapist can only be disclosed upon notice to the individual patient (CA Civil Code §56.104).

Anthem agrees that notice must be sent by the entity making the request for the outpatient psychotherapy information. As a result, Anthem will send notice to any member covered under the law within thirty (30) days of receipt of the records, as required by the law.

As to disclosure of information related to outpatient psychotherapy records of California residents, if your practice already notifies your patients as required by California Civil Code 56.104, you should be able to submit psychotherapy records to Anthem pursuant to Anthem's record request.

6. How often will the chart requests occur?

Throughout the year, Inovalon, Inc. will schedule the collection and/or review of medical record/chart information for members who have had services rendered by your provider practice or facility.

7. Do patients have to provide their permission for records to be released to Inovalon?

No, patient-authorized information releases are not required in order for you to comply with these requests for medical records. Providers are permitted to disclose Protected Health Information to health plans without authorization from patients when both the provider and health plan had a relationship with the patient and the information relates to the relationship [45 CFR 164.506(c)(4)]. For more information regarding privacy rule language, please visit http://www.hhs.gov/ocr/privacy.

8. Is this chart collection process HIPAA compliant?

Yes. According to HIPAA Privacy Rules (CFR 160, 164), amended August 14, 2002, health care providers can disclose Protected Health Information (PHI) to health plans for the purpose of quality assurance, quality improvement, accreditation activities and approved research studies. As defined by HIPAA, the role of the company performing the chart collection, Inovalon and its contractors, is as a "Business Associate" of the Anthem health plan, which is a "Covered Entity," and as such, Inovalon is ethically and legally bound to protect, preserve, and maintain the confidentiality of any PHI it gleans from clinical records. In this setting, Inovalon is required to treat your patients' PHI with the highest level of protection and confidentiality. Please know that we consider the confidentiality of patient information to be of the utmost importance. A copy of the Business Associate agreement is available upon request from Inovalon at 1-877-448-8125.

9. What is the benefit to providers for participating with these medical record requests? Is the medical record review mandatory?

Participation is encouraged to achieve several benefits. Clinical diagnosis data accuracy leads to improved risk score insight and accurate financial reimbursement for care provided. Additionally, appropriately reimbursed health plans are able to maintain stable member premiums and create new member programs to help improve health care outcomes.

It is highly likely that the contractual agreement between Anthem and the provider requires the provider to produce the requested medical records. Please review your contractual agreement with Anthem.

10. I am not a network-participating provider with Anthem. Why do you need my information?

We have identified at least one patient who was seen at your office practice or facility during the requested date of service range. Our records show that a claim was submitted to us for the visit.

11. Who should I contact if I have questions about the medical record review process or the Inovalon effort?

Please contact Inovalon toll free at 1-877-448-8125 if you have additional questions about their outreach effort or the medical record review process.