HEDIS Medical Record Reviews Coming Soon

As many of you know, it is the time of year when Community Health Plan of Washington (the Plan) and other health plans prepare to review a sampling of members' medical records for the HEDIS® program.

What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to ensure that purchasers (employers and governmental entities) and consumers have the information they need to reliably compare the performance of managed health care plans.

HEDIS is maintained by the National Committee for Quality Assurance (NCQA) and accounts for approximately 30 percent of a health plan's NCQA accreditation score. HEDIS data is audited by NCQA certified third party vendors.

For Medicaid (Healthy Options/CHIP and Disability Lifeline/GA-U) and Commercial (Basic Health and Washington Health Program) lines of business, our auditing firm is HSAG (Health Services Advisory Group). For Medicare, it is Thomson Reuters.

The data is reported publicly by NCQA, state governmental agencies, the Association of Community Affiliated Plans, US News Health Plan Rankings, and other national communications.

Why is medical record data needed?

HEDIS data is collected first from our medical and pharmaceutical claims processing systems. This is called administrative data. If the required information is not found in the administrative data, then the medical records must be reviewed for some HEDIS topics (known as HEDIS measures).

What is new for the 2011 HEDIS medical record review process?

Community Health Plan heard your feedback about past experiences with our HEDIS medical record review vendors. This year we are happy to announce that we will send Plan employed and trained reviewers to locations rather than rely on vendors. In addition, more information will be reviewed electronically, on site at your location or remotely. Furthermore, more of our larger provider locations have consolidated their medical records at one central location. These steps should make the process smoother.

What diseases or conditions are reviewed in the medical record?

HEDIS organizes diseases or conditions into groups called domains. There are eight domains. Within each domain there are many diseases or conditions (HEDIS measures). Not all measures allow for medical record review.

The Plan's reviewers will look at three domains: Effectiveness of Care, Access/Availability of Care, and Use of Services. Within those domains, they will specifically review:

  1. Effectiveness of Care
    1. Adult BMI Assessment
    2. Care for Older Adults
    3. Cervical Cancer Screening
    4. Childhood Immunization Status
    5. Cholesterol Management for Patients with Cardiovascular Conditions
    6. Colorectal Cancer Screening
    7. Controlling High Blood Pressure
    8. Comprehensive Diabetes Care
    9. Medication Reconciliation Post-Discharge
  2. Access/Availability of Care: Prenatal and Postpartum Care
  3. Use of Services
    1. Adolescent Well-Care Visits
    2. Well-Child Visits in the First 15 Months of Life
    3. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

When will I find out if the Plan needs to review records at my location?

In March 2011 you will find out which, if any, medical records need to be reviewed. You will receive either a phone call and fax list or just a fax list (if the number of medical records is very small).

We sincerely appreciate your help in making this a successful review process and in welcoming the reviewers to your site.