Standards for Treatment Record Documentation

Humana Behavioral Health has developed guidelines for treatment record documentation, standards for availability of treatment records and performance goals to define expectations for practitioners.

Annual Assessment of Provider Compliance

Treatment Record Documentation (link opens in new window)

Humana Behavioral Health monitors network providers to determine compliance with treatment record documentation standards. High volume practitioners are monitored regularly along with, other providers who may be subject to ongoing documentation review. The performance goal is 85 percent and the reviews are conducted in the practitioner’s office to allow for face-to-face contact and training.

During record reviews, Humana Behavioral Health will assess a random selection of treatment records to ensure that network practitioners comply with these guidelines and standards. In addition, administrative management of records is also assessed.

The sample selection represents 50 percent of the high volume practitioners in each market where Humana Behavioral Health has business. High volume is defined as a practitioner who sees 10 or more enrollees three or more times in a 12-month period.

Expectations for Treatment Records

The following are the Humana Behavioral Health expectations for treatment record keeping practices:

  • Treatment records are maintained in a manner that is current, detailed and organized.
  • Confidentiality of treatment records is maintained according to applicable state and federal regulations.
  • Practitioner office staff is trained and experienced in handling confidential information. Evaluation/re-training is conducted at regular intervals.
  • Access to treatment records is limited to appropriate staff members in the office setting and in secure storage. Records must be organized and retrievable to ensure availability to practitioners, office staff, Humana Behavioral Health and the courts, if subpoenaed, or as required by law/statute.
  • Practitioners assure that any request for records is legally permissible prior to making an associated disclosure.
  • All requests for consultation and lab reports are documented. Additionally, the review of reports from such requests is documented.
  • Purging of treatment records is done according to state law.

Download and Print

The exact standards for keeping treatment record documentation are available below and In the provider manual. You may also obtain a paper copy by calling 1-866-279-7214.

Standards for Treatment Record Documentation

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English (link opens in new window)