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described in lhe applicable addenda or the Administrative Manual.
<br />4.4 MAINTENAJ:IIC J; _NJJ .. ~ETENTION OF RECORDS -MedlcaJ Group will maintain
<br />medical, fina11.ciaJ and administrative records concerning sesvloes provided to Members in
<br />accordance •wilh Co111pany ·s requirements, applicable federal and a_tate laws and
<br />generally accepted bu&lness and professional practices. Medical Group WIii ensure that
<br />a medical record is established and maintained for each Member who receives services
<br />from Medical Group in accordance with Company's standards. This record will be
<br />opened at the time of a Member's first visit and shall include contemporaneous , written
<br />documentation of the Member's condition, the treatment and services provided, the date
<br />on wh ch the ser:vices were prov ded , and the identity of the provider rendering the
<br />services. Alterations or S!'flendments lo records must include the date and time of the
<br />alteration or amendment and the signature of the person mak ng the alteration or
<br />amendment. Company may deny cla ims In those cases wt,ere, in the Company's sole
<br />discretion , there_ Is Inadequate documentation of the .services r~ndered , In wh ich case lhe
<br />Medical Group shall not blll lhe Member. Medical Group will maintain such records for a
<br />period of at leas! ten (10) years from the date of service or from the date a Member
<br />aNalns the age of majorit11, Whichever is later, The obligations of Medical Group under
<br />th is section will survive the term ination of U,ls Agreement, regardless of the cause giving
<br />rise to such termination.
<br />4.5.1 Company, its aulhoriied representalllles and govemment agencies, will have the
<br />right to audit and make .or obtain cop es of medical, financial al'ld administrative
<br />re co rds , directly rela ed ,to servi ces rendered to Membeni rar purpo5es •that may
<br />nc;l ude, but nol be Umlted · to: accuracy of claims , coverage for services, medical
<br />necessity, proper utlllzatlon, appropriateness of seivices, CredenOailng and
<br />R.ecredentlallng, and quality Improvement and appropriateness of bllllng, upon
<br />reasonable notice, during regular bc.isiness hours of Company. The . Company
<br />also mav conduct desl< audits of !lie Medical Group'il racillly(las) and Member's
<br />records. Company. shall provide Medical Group with at least three (3) btlslnes:s
<br />clays advance no ice of s1,1cll a_udlt unless Company determines there Is a
<br />s gniflcant quality of care IISue ot risk tttat documents may be altered, createo or
<br />destroyed. In such case . Co111panv may conduct an audtt upon twenty-tour (24)
<br />·hour's adlll!noo notice . Notice of the audit shell appr se lhe Medlcal Group of the
<br />period of time for which records are to be audited . The provider agrees to have
<br />all records for that period avallable at the time ol the audit Records not
<br />produced at the time of the audit will be deemed non-existent. Audils shall be
<br />conducted n a manner 1hat, to lh~ greatesrextent possible, ,avoids di!jtupt!on of
<br />the provider's business affairs and minimizes the burden on the Medical Group .
<br />Audits wlll comply with all law$, sllltute.s and regulalfons perta fn lng to the
<br />confiden!lality of medical and financial records. Copie.s of records requested by.
<br />the Company or Ila representalive will be furn ished lo the Comp~ny upon request
<br />and wllhout charge lo lhe Company or Members, except ro , records related to
<br />utilftallon management review, which shall be 'reimbursed al \he rates set fotth fn
<br />the Administrative Manual.
<br />4.5,2
<br />Insofar as Members are required to execute an authorization for the release of
<br />their medical records to Company upon becoming Members, Medical Group
<br />agrees to accept from Company, as a legally sufficient release of Members'
<br />med cal records, Members' participation In Healih Plans of Company and
<br />Company will not be required to obhtin an additjo1,1al medical rele!fse fonn from
<br />Members in order lo Inspect, review, or make copies of Members' medical
<br />records. This provision will survive the termination of this Agreement, regardless
<br />of the cause giving riae to such termination.
<br />Companfs remedies for the Medl~I Group's failure to cooperate With an aud it or
<br />for insufficient documentatJon , lnBJ)proprlate billing, or substandard quall1y of care
<br />Aaurfa MGA Agniemant (Rell. 05/Z017) A1881685-4AA Pnae 10 of 20
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