Medical Records Request

  • Medical records requests are a key part of quality and risk adjustment activities. This effort ensures that our members have access to quality, affordable healthcare.

    Your office may receive medical records requests to support the following programs:

    • Commercial risk adjustment
    • Medicare Advantage risk adjustment
    • Marketplace (Exchange) HEDIS
    • Medicare Advantage HEDIS/5-Star Rating

    The success of these programs relies on provider partnership in three key areas:

    • Claims coding that is complete, accurate, and timely
    • Medical record documentation that validates completion of clinical care and substantiates claims
    • Submission of select medical records to support coding and documentation reviews and audits and to validate completion of clinical care to supplement claims data

    We'd like to make sure the right person in your office receives the medical records requests - please send us an email with the name and email address of the ideal contact in your office.

    Requests start October 2016 and continue through December 2017 - here's an overview for your reference:

    Quality Program Commercial Risk Adjustment Commercial/Marketplace (Exchange) HEDIS
    Purpose of Record Retrieval: Validation of diagnoses in the medical record to claims submitted
    Initial validation audits by CMS (Centers for Medicare & Medicaid Services)
    Data collection of Clinical Quality Measures to submit to NCQA (National Committee for Quality Assurance)
    Vendor: Altegra
    Third-party auditor in conjunction with CMS
    Verisk Health
    Begins: October 2016
    Summer 2017
    January 2017