The Blue Cross and Blue Shield of New Mexico (BCBSNM) Quality Improvement Department performs an annual medical record review audit to assess whether practitioners/providers meet the minimum New Mexico Administrative Code (NMAC) and BCBSNM medical record documentation standard requirements for members who are serviced under the Blue Cross Community CentennialSM network. Medical records are also evaluated against BCBSNM established medical record standards.
BCBSNM randomly selected 10 primary care, obstetrics, and gynecology providers who had at least 10 member encounters between September 2021 and August 2022 where members had at least two visits within the specified timeframe. BCBSNM requested medical records across the 10 provider groups. BCBSNM staff assessed and scored all charts against NMAC and BCBSNM medical record standards. BCBSNM has an established overall goal of 80% or better for NMAC medical record standards. Although BCBSNM-established medical record standards are scored and held to the same 80% or better threshold, this is not part of the cumulative score for the medical record review audit. This score is more for informational and reporting purposes only.
Should a provider group not meet the minimum threshold of 80%, BCBSNM may require that provider submit a corrective action plan to the Quality Improvement Department. Per policy, Providers who fail the medical record audit will be included in the next annual medical record review. Results are presented to the Quality Improvement Committee (QIC) for consideration and feedback. The QIC consists of medical directors, external practitioners, and BCBSNM management.
| Overall Medical Record Review Score | 2022 Results | 2021 Results | 2020 Results | 2019 Results |
| 80% to 100% | 8 | 10 | 15 | 19 |
| ≤79% | 0 | 0 | 0 | 1 |
| No Response | 1 | 0 | 5 | 2 |
| Ineligible | 1 | 0 | 0 | 0 |
Providers who are randomly selected are provided a copy of NMAC and BCBSNM standards to review as part of the initial medical record request. Of those providers who provided medical records (8 out of 10), scored higher than the 80% threshold for NMAC medical record requirements. One provider did not provide the requested records, while the other was removed from the sample because they did not meet the sampling methodology requirements.
The Medical Record Review standards can be found under the Resources section on the Medicaid page of the provider website. BCBSNM would like to thank those providers who provided medical records timely. Should you have any questions or need further information about the medical record audit or any other Quality program activities, please contact the BCBSNM Quality Improvement Department at 1-855-699-0042 or submit your inquiry to qualityinquires@bcbsnm.com.