February 1, 2017
During February to early May of 2017, you may be contacted by Verscend, a Premera partner organization, about a medical records review. (Verscend was previously known as Verisk Health.) The medical records review is part of our data collection for the Clinical Effectiveness of Care Measures, part of the Healthcare Effectiveness Data Information Set (HEDIS)®. Reporting HEDIS measures is also required for our participation in the Affordable Care Act's Health Insurance Marketplace, formerly known as the Exchange.
If you care for Premera Medicare Advantage patients, you may hear from Providence Health Plan (acting on behalf of Premera) regarding medical records reviews for these patients.
What to expect
NCQA limits all health plan medical record collection to a set time period from February to early May. Medical records for one or more of your patients may be identified for review during those months, and our partner Verscend may contact you. You may submit records through secure online upload, fax, or mail. When the Verscend team sends you a chart request, they will include instructions for submitting the records. Verscend will contact if you if the submitted records are incomplete, illegible, or otherwise unclear.
Member authorization consent
In addition to being permitted under HIPAA, we secure the consent of our members for release of medical records upon enrollment. You should not provide to us (or to Verscend) any medical record information related to psychotherapy, HIV, substance abuse, or genetic testing-and we won't request this information either.
HEDIS® data and HIPAA guidelines
The HIPAA Privacy Rule permits a provider to disclose protected health information to a health plan for the quality-related health care operations of the health plan, provided that the health plan has or had a relationship with the individual who is the subject of the information, and the protected health information requested pertains to the relationship. See 45 CFR 164.506(c)(4). A provider may disclose protected health information to a health plan for the plan's Health Plan Employer Data and Information Set (HEDIS) purposes, so long as the period for which information is needed overlaps with the period for which the individual is or was enrolled in the health plan.
About HEDIS
HEDIS is a set of quality measures used by more than 90 percent of US health plans to assess performance on important dimensions of quality and service. HEDIS is managed by the National Committee for Quality Assurance (NCQA), a private, nonprofit organization dedicated to improving healthcare quality. Medical records from our members' physicians are required in order to compile the necessary data for some of the HEDIS measures.
If you or your staff have questions regarding the retrieval of medical records and the HEDIS data collection process, contact Physician and Provider Relations at 877-342-5258, option 4 or your network contract specialist. Thank you for your collaboration in improving quality of care.