Escalation Protocol

Internal Escalation

100

What needs to be considered before escalating?

• The request has been assigned to the correct provider. 
• The request has been addressed to the correct provider (correct provider name & address). 
• The request has been sent to the correct location/department. 
• Confirmation whether request has been confirmed as received by provider/copy service, and if so, when, and how.

200

Mention 5 steps when proceeding with internal escalation

1. Call daily

2. Send follow-up fax/email

3. Speak with someone else when representative is not helpful

4. Search online for different contact info 

5. Search in our RLLS system for possible completed requests 

6. Speak to an office manager/supervisor/privacy officer

7. Inform provider they have 30 days to fulfill the request 

8. Review medical records that have been already received for further provider info

9. Check if a previous RR has received documents 

10. Document all attempts.

300

What are the scenarios where we need to escalate

1. provider exceeded 30 calendar days w/o notification

2. exceeded 30 days, and they asked for an extension

3. Provider refuses to provide information due to unreasonable reasons 

4. Provider is completely unresponsive

HIPPA Request Escalation

100

What is the difference between internal escalation and HIPAA request escalation?

Internal escalation means we exhaust all options we have to reach the provider to obtain records within 30 calendar days, and HIPAA request escalation is when provider incurs in the HIPAA violation for not releasing the records within the 30 calendar days, and if necessary an OCR complaint could be filed with CM's approval. 

200

What are the steps for Stage 1 ?

1. Verify with the provider the POC to escalate

2. Send a warning letter along with original request and supporting documentation

3. Follow up on escalation with the provider, and if unresponsive, consult with TL or CSR to create a ticket for OCR Complaint

300

What do we do on Stage 2 ?

1. Follow up on the ticket approval 

- If approved, file the OCR complaint
- If not approved, follow up for 2 weeks 

2. If no response for the ticket, allow 15 calendar days for the CM to respond (CSR follow-up)

HIPAA

100

What is HIPAA ?

Health Insurance Portability and Accountability act, it is a law designed to protect PHI.

200

How long does a provider have to release records under HIPAA Law?

30 calendar days 

300

What is a HIPAA Violation?

Any failure to comply with the HIPAA regulations – which can include the unauthorized access, use, or disclosure of Protected Health Information (PHI),  and the failure to provide patients with access to their PHI.