Medical Records Review: February 2020

  • January 1, 2020

    This spring Premera will be working with COTIVITI, a Medical Record Retrieval services. This is part of our data collection 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.

    What to expect

    Medical records for one or more of your patients may be identified for review from February to May, and you may be contacted by COTIVITI.

    You may submit requested records through secure online upload, fax, or mail. When the COTIVITI team sends you a chart request, they will include instructions for submitting the records. COTIVITI will contact you if the submitted records are incomplete, illegible, or otherwise unclear.

    Why is Premera involved?

    Medical records from our members’ physicians are required in order 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’s Health Insurance known as The Exchange.

    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 us (or to COTIVITI) with 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 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.

    If you or your staff have questions about medical records retrieval and the HEDIS® data collection process, please contact your network contract specialist, or the Premera Network Relations Department at 425-918-4000 Western WA, 509-252-7460 Eastern WA or 800-722-1471.

    Thank you for your participation in HEDIS® and for your collaboration in improving quality of care.

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