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 through Premera and its vendors for:
- 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 audit 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 |
Medicare Risk Adjustment |
Commercial/Marketplace (Exchange) HEDIS |
Medicare HEDIS (5-Star Rating) |
| Purpose of Record Retrieval: |
Validation of diagnoses in the medical record to claims submitted
Risk Adjustment Data Validation (RADV) Audit by Centers for Medicare and Medicaid Services (CMS) |
Validation of diagnoses in the medical record to claims submitted
Risk Adjustment Data Validation (RADV) audit by CMS |
Data collection of Clinical Quality Measures to submit to NCQA (National Committee for Quality Assurance) and CMS |
Data collection and validation of Clinical Quality Measures to submit to NCQA and CMS |
| Vendor: |
Change Healthcare and CIOX Health
Cognisight in conjunction with CMS |
Advantasure and CIOX Health
Premera, Advantasure, and CIOX Health |
Cotiviti |
Providence Health Plan as third-party administrator for Premera |
| Begins: |
Annually, starting in October
Annually, early summer |
Annually, April to December
As determined by CMS |
January to December, with increased intensity February to May, annually |
January-December with increased intensity February-May, annually |