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Preventive and clinical practice guidelines are based on the health needs and opportunities for improvement identified as part of Quality Assurance Program Improvement (QAPI). Whenever possible, Aetna Better Health® of Illinois adopts preventive and clinical practice guidelines that are published by nationally recognized organizations or government institutions, as well as state-wide collaboratives and/or consensuses of health care professionals in the applicable fields.
Aetna Better Health providers must keep accurate and complete medical records. Such records will enable providers to render health care service to members. They will also enable us to review the quality and appropriateness of the services rendered. We conduct random medical record audits as part of QAPI to monitor compliance with medical record documentation standards.
The coordination of care and services provided to members, including over utilization and under utilization of specialists and the outcome of such services, may be assessed during a medical record audit. We provide written notice prior to conducting a medical record review.