March 18, 2021
This spring, Premera is working with COTIVITI to collect data for the Clinical Effectiveness of Care Measures, part of the Healthcare Effectiveness Data Information Set (HEDIS®).
What is HEDIS?
HEDIS is a set of quality measures used by more than 90 percent of U.S. 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. HEDIS measures address a range of health issues including preventive care screenings, controlling high blood pressure, comprehensive diabetes care, access and availability of care, and behavioral health.
Why is Premera involved?
Medical records from our members’ physicians are required to compile the necessary data for some of the HEDIS measures.
Reporting HEDIS measures are also required for our participation in the Affordable Care Act, also known as The Exchange.
What to expect
Medical records for one or more of your patients may be identified for review during those months, and you may be contacted by COTIVITI to provide these medical records. NCQA limits all health plan medical record collection to a set time from February
to early May.
Records may be submitted through secure online upload, fax, or mail. COTIVITI will send instructions for submitting the records with the request.
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 COTIVITI) any medical record information related to psychotherapy, HIV, substance
abuse, or genetic testing—and we will not request this information.
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 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.
If you or your staff have questions regarding the retrieval of medical records and the HEDIS data collection process, contact your network contract specialist, or the Premera Network Relations Department at 800-722-1471.
We appreciate your participation in HEDIS and your collaboration in improving the quality of care.