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5.20.2014 Supplemental Data Guidelines If a patient does not remember the exact date and location of a test or procedure, what is the minimum acceptable documentation for satisfying the supplemental data requirement for this measure? How specific does this information have to be? May member-reported data be entered into a legal health record by staff members?

General Guideline 28 outlines the requirements for using member-reported supplemental data, which may be accepted only when accompanied by proof-of-service documentation from the legal health record. If proof-of-service documentation is not available, member-reported information on services rendered (patient history) are acceptable only if taken by a PCP as part of the member’s history. Information must be signed, dated and maintained in the member’s legal health record. General Guideline 29: Date Specificity addresses measures that include date requirements in order to achieve numerator compliance. Dates must be specific enough to determine that the event occurred during the period specified by the measure. 

 

ALL 2013