To be considered complete, documentation for episodes of care will include at a minimum the following elements:

Patient identifying information

Consent forms

Health history, including applicable drug allergies

Types and dates of physical examinations

Diagnoses and treatment plans for individual episodes of care

Physician orders

Face-to-face evaluations

Progress notes

Referrals

Consultation reports

Laboratory reports

Imaging reports (including X-ray)

Surgical reports

Admissionand discharge dates and instructions

Preventive services provided or offered appropriate to the member's age and health status

Evidence of coordination of care between primary and specialty physicians

Refer to the standard data elements to be included for specific episodes of care as established by The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition.

Documentation for all episodes of care must meet the following criteria:

Is legible to someone other than the writer

Contains information that identifies the member on each page in the medical record

Contains entries in the medical record that are dated and include author identification (e.g., handwritten signatures, unique electronic identifiers or initials)

Other documentation not directly related to the member
Records should contain information relevant to support clinical practice and used to support documentation regarding episodes of care, including:

Policies, procedures and protocols

Critical incident/occupational health and safety reports

Statistical and research data

Clinical assessments

Published reports/data

IntegraNet may request that you submit additional documentation, including medical records or other documentation not directly related to the member, to support claims you submit. If documentation is not provided following the request or notification or if documentation does not support the services billed for the episode of care, we may:

Deny the claim.

Recover and/or recoup monies previously paid on the claim.

Section 1833(e) of the Social Security Act, states that Medicare payment can be made only when the documentation supports the service/item. IntegraNet is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation