Medical records documentation

Humana Military may review a provider’s medical records on a random basis to evaluate patterns of care and compliance with performance standards. Policies and procedures should be in place to help ensure that a beneficiary’s medical record is kept organized and confidential. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis and describe the patient’s progress and response to medications and services. The medical record must also substantiate the services or supplies on submitted claims.