Insurance Audit Questionnaire

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Below are the typical items and the questionnaire used to audit a client's file.

Requested Documentation:

  1. Client demographic or registration information.
  2. Health First Colorado (Medicaid specific) Client Rights and Responsibilities form.
  3. Provider disclosure information (DORA).
  4. Privacy notice acknowledgment (HIPAA).
  5. Initial assessment, clinical formulation or summary, and diagnosis.
  6. Assessment update for anyone in treatment longer than one (1) year after initial assessment
  7. Initial treatment plan and any subsequent updates.
  8. Progress notes from the latest six (6) months of the Member’s treatment (prior to discharge or prior to current date).
  9. Coordination of care releases of information and letters or contacts with other providers.
  10. Documentation of access and engagement (please see audit form for details).
  11. Evidence of supervisor sign-off on diagnosis and treatment plan for work done by non-licensed staff or interns, along with periodic evidence of supervisor case review.

View Google Sheet:  Client Audit Tool used by Insurance

Questionnaire/Evaluation

    

C8

Tx plan identifies agencies/other providers involved in client care along with the services they are providing.

    

C9

Tx plan is signed and dated by the client/guardian; reason given if not signed or if client doesn't agree.

    

C10

Tx plan is signed by the appropriate licensed practitioner of the healing arts (LPHA). A licensed clinician must sign the plan if it orders therapy or rehab services; a physician must sign the plan if medication or nursing services are ordered OR if the client is dual Care/Caid. Unlicensed providers at MHCs must have cosigner who is licensed individual.

    

C11

Supervisor co-signed tx plan for interns and non-licensed staff

    

C12

Child's tx plan includes how family/guardian will be involved to address child's issues or reason why their involvement is inappropriate.

    

C13

Discharge criteria established. (e.g., levels of change necessary to achieve 'graduation' from tx)

    

C14

Assessment review and tx plan update completed as needed, at least every 6 months for MHC and 12 months for independent providers.

     

SECTION D: Progress Notes Requirements:

Met

Partly Met

Not Met

NA

D1

Nature and frequency of services correspond to those ordered on the tx plan. Alterations in nature/frequency are documented as necessary.

    

D2

Each progress note includes date of service, place, time, duration, persons present, CPT/procedure code, signed by provider w/ credentials, date signed.

    

D3

Each note refers to the goals & objectives from the current tx plan being addressed in that session.

    

D4

Notes describe skilled clinical interventions or techniques used by provider.

    

D5

Client's response to intervention & progress toward goal is described in each note.

    

D6

Supervision of interns and non-licensed providers is evident in notes and or with co-signatures on notes

    

D7

Interpretation when needed is documented in session note and provided by a non-family member.

    

D8

Notes address suicide risk as needed until risk is resolved.

    

D9

Notes address needs such as medical, dental or SUD prn with referral to additional services as needed.

    

D10

Evidence present of outreach to clients who no show for appointments or drop out of services.

     

SECTION E: Coordination of Care

Met

Partly Met

Not Met

NA

E1

Document date of last physical exam. Adults/children with no exam in last year or no primary care provider are referred to local clinic or to Colorado Healthy Communities to find a physician.

    

E2

Statement that patient refused coordination of care is present if they refused.

    

E3

Provider sent Coordination of Care letter yearly to PCP (not psychiatrist) with notice of enrollment and diagnosis. Does not apply if there is not a proper release.

    

E4

For clients 18+, evidence that provider asked if client has Advanced Directive and offered educational information. (see Health First CO Rights and Responsibilities form).

    

E5

For clients under 21, evidence that provider educated client/parent about EPSDT services as needed. (see Health First CO Rights and Responsibilities form)

    

E6

Provider assessed for health/services needs other than MH and made appropriate referrals. Documents follow up on referrals made.

    

E7

Evidence of coordination/ case management with non-medical providers (child's school, social service agencies, etc.) noted as applicable. Note includes person contacted and content of conversation.