Provider Manual


Providers are expected to cooperate with treatment record reviews conducted by Beacon as part of health plan operations. These reviews may occur:

  • In response to a specific quality issue or concern that arises.
  • To meet account or accreditation agency requirements mandating review on a periodic basis or upon request.

Beacon will gain access to treatment records by reviewing them at the provider’s office or by asking the provider to photocopy and send the records. Prior to treating a member, the provider should obtain the member’s written consent to share their treatment information and records with Beacon. Providers must supply copies of requested records to Beacon within five (5) business days. Beacon will treat provider records confidentially as per all applicable Federal and State regulations.

Providers and vendors must, at their own expense, make all records available for audit, review or evaluation by Beacon Health Options. Access shall be provided by the provider either on-site, during regular business hours, or through the mail. During the contract and record retention periods, these records shall be available at a specific location. All mailed records shall be sent to Beacon in the form of accurate, legible, paper copies, unless otherwise indicated, within fifteen (15) calendar days of such request and at no expense to Beacon.

Following the treatment record review, providers will receive a written report that details the findings. Included in the report will be an Action Plan with specific recommendations that will enable the provider to more fully comply with Beacon’s standards for treatment records.

Treatment records are reviewed through application of an objective instrument. The instrument is continuously under study and revision and Beacon reserves the right to alter it as needed.

For the purpose of conducting retrospective case review, clinical files pertaining to Beacon members should be maintained for six (6) years.

Beacon network providers are required to document service accessibility for the services that are provided. A network provider must provide face-to-face interventions within one hour for emergencies, within 24 hours for urgent situations, and within seven days for routine appointments and specialty referrals. Beacon collects and analyzes this data to measure performance against these contract standards. As part of a routine treatment record review, Beacon will audit for the following quality management criteria:

  • The date of the member’s initial call for an appointment,
  • The type of appointment, such as emergency, urgent or routine,
  • The date of the first appointment offered,
  • The date and the time of the actual evaluation appointment, and
  • The documentation of the reason the standard was not met, if applicable.

Diagnostic guidelines and diagnostic adherence indicators for major depression, bipolar disorder, schizophrenia, attention-deficit hyperactivity disorder, and co-occurring mental and substance related disorders are posted on our website for reference on the Provider Information Page under the Quality Management section.