Medical Records Request

  • Medical records requests are a key part of quality and risk adjustment activities. This effort ensures that our members have access to quality, affordable healthcare.

    Your office may receive medical records requests through:

    • Commercial risk adjustment
    • Medicare Advantage risk adjustment
    • 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

    We'd like to make sure the right person in your office receives the medical records requests - please send us an email with the name and email address of the ideal contact in your office.

    Requests start October 2016 and continue through December 2017 - 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
    Initial validation audits by CMS (Centers for Medicare & Medicaid Services)
    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) Data collection and validation of Clinical Quality Measures to submit to NCQA and CMS
    Vendor: Altegra
    Third-party auditor in conjunction with CMS
    Providence Health Plan or RMC (Reimbursement Management Consultants)
    Premera or Providence Health Plan
    Verisk Health Providence Health Plan as third-party administrator for Premera
    Begins: October 2016
    Summer 2017
    June-December 2017
    As determined by CMS
    January 2017 January-December with increased intensity February-May 2017