Insurance Audit Questionnaire

Table of Contents

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

Requested Documentation:

Client demographic or registration information.
Health First Colorado (Medicaid specific) Client Rights and Responsibilities form.
Provider disclosure information (DORA).
Privacy notice acknowledgment (HIPAA).
Initial assessment, clinical formulation or summary, and diagnosis.
Assessment update for anyone in treatment longer than one (1) year after initial assessment
Initial treatment plan and any subsequent updates.
Progress notes from the latest six (6) months of the Member’s treatment (prior to discharge or prior to current date).
Coordination of care releases of information and letters or contacts with other providers.
Documentation of access and engagement (please see audit form for details).
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

	ACCESS STANDARDS	Met	Partly Met	Not Met	NA
*1	ACCESS: Documentation shows date of first request for service and that intake offered within 7 business days
*2	ENGAGEMENT: Client has 4 appts. Within 45 days of admission.
*3	EMERGENCY ACCESS: Provider gives emergency instructions in written documents that includes State Crisis number rather than 911 or referral to ER
	SECTION A: Administrative Requirements	Met	Partly Met	Not Met	NA
A1	Record is legible to reader
A2	Client Demographic Data is present, including name, address, phone, gender, DOB, Medicaid #, Emergency Contact, consent to treat
A3	Signed Health First CO Rights and Responsibilities form is present; reason given if not signed
A4	Signed Acknowledgement of Notice of Privacy Practices is present; reason given if not signed (HIPAA)
A5	Mandatory Disclosure Form signed by 2nd appt.; reason given if not signed. (Does not apply to MDs or Nurses) - see CRS 12-43-214
	SECTION B: Assessment Requirements:	Met	Partly Met	Not Met	NA
B2	Record contains information on chief complaint, precipitating factors leading to request for services
B3	Presenting problem detail includes specific signs & symptoms, onset & duration, changes in functioning, and previous efforts at self-help
B4	Mental Status Exam is present. Includes Appearance/Behavior, Orientation, Memory, Speech, Attention, Intelligence/Fund of knowledge, Mood/Affect, Thought processes, Judgment, Insight, Perceptions
B5	Risk Assessment present for suicide/homicide at intake; more in-depth assmt occurs if risk identified.
B6	If client at risk for suicide/homicide, provider has safety plan in place and instructs re emergency care. Refers to higher level of care or adds additional contact, prn.
B7	Assessment identifies cultural/spiritual factors that may impact treatment or the therapeutic relationship, or says none were identified. (Factors such as age, values/beliefs, preferred language, communication needs, gender, sexual orientation, relational roles, among others). States how services will be adjusted to address these factors.
B8	Transportation needs were assessed for adult patients. Provider referred for transportation assistance prn
B9	Psychosocial history includes living arrangements, guardianship, interpersonal relationships, vocational, physical/sexual abuse/perpetration & victimization; legal problems, violence, military service. (List items missing, if any)
B10	Prior psychiatric treatment noted or statement that it is not applicable. Records requested as needed.
B11	Assessment includes family history of mental illness, medical problems and substance abuse problems
B12	Developmental history for clients < 18 y/o includes pre/perinatal events, physical/emotional/social/ intellectual growth & development, school adjustment & performance, typical activities & interests, behavior mgmt skills, social skills issues
B13	Past or present substance abuse of tobacco, alcohol, illicit substances or prescribed meds assessed for those over 12, or statement that this it not applicable. Includes amount & frequency of use, problems associated w/ use, and whether or not specialty tx is needed.
B14	For adults, MR/DD/organic conditions that may impact clinical presentation or functioning noted or statement that this is not applicable.
B15	Medical and dental history is present or statement that this is not applicable. (includes current medications, allergies to meds)
B16	DSM-V diagnosis consistent throughout record. Any change in dx documented and explained.
B17	Diagnosis approved by supervisor if done by intern or non-licensed staff
B18	Succinct clinical formulation/summary is present and includes: 1) symptoms/ behaviors per DSM which justify dx, 2) other dx to consider, 3) initial goals/proposed interventions before tx plan developed; 4) recommended type and frequency of services; 5) whether referrals are needed for other/additional services
	SECTION C: Treatment Planning Requirements:	Met	Partly Met	Not Met	NA
C1	Treatment plan completed within 14 days of intake, reason stated if not present or complete.
C2	Individualized goals/objectives correspond to diagnosis and/or identified needs.
C3	Risk issues identified are addressed in plan.
C4	Objectives are measurable and achievable ("as evidenced by"), relate to the problems presented, and include estimated time to completion.
C5	Tx plan includes client strengths, and strengths are used to promote goal achievement.
C6	Tx plan prescribes skilled interventions for each goal and how often the intervention will be provided.
C7	Interventions are in keeping with generally accepted practice, appropriate for presenting problem/ diagnosis, and tailored to cognitive/developmental level of client.
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.