Highmark strives to improve the resources we make available to you. The Highmark Provider Manual, your primary reference source, is meant to simplify your experience by providing one all-inclusive provider manual for all provider types in all of our services areas. And we continually review and update the manual to better meet your needs.
Chapter 4.7: Medical Records Documentation Requirements is the latest edition to the Highmark Provider Manual. This unit was developed to provide guidelines for documenting members’ medical records that will help you to have the appropriate documentation readily available for medical necessity reviews. This will help us to ensure accuracy of billed claims data and, therefore, prevent delays in reviews and payment.
Medical record documentation is necessary to record applicable observations and findings regarding the member’s history, examinations, diagnostic tests and procedures, diagnoses, treatments and treatment plan, necessary follow-up care, and outcomes or responses to care per date of service or encounter.
Additionally, the medical record serves as a formal document and a communication tool between providers, vendors, and Highmark. All medical documentation must be maintained in the member’s medical record and, if requested, made available to Highmark or its contracted vendor by the requested date.
Furthermore, providers are responsible for adhering to professional standards, as well as applicable laws, regulations, and directives, with respect to medical recordkeeping and documentation.
This new unit contains information about:
