Medical records requests are a key part of quality and risk adjustment activities. This effort ensures that our members have access to high quality, affordable healthcare.
Your office may receive medical records requests to support the following programs:
- Commercial risk adjustment
- Medicare Advantage risk adjustment
- Commercial HEDIS
- 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
Requests are generated at different times during the year based on the purpose for the request. 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 Centers for Medicare and Medicaid Services(CMS) |
Data collection of Clinical Quality Measures to submit to NCQA (National Committee for Quality Assurance) and CMS |
| Vendor: |
Change Healthcare and CIOX Health
Cognisight in conjunction with CMS |
Cotiviti |
| Begins: |
October, annually
Early Summer, annually |
January, annually |