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Medical Record Review for HEDIS Begin in February

In the coming weeks, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will collect our members’ medical records for the annual Healthcare Effectiveness Data and Information Set (HEDIS®) reporting requirements. HEDIS is required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Advantage organizations. It is used for the National Committee for Quality Assurance (NCQA) accreditation, and to monitor quality initiatives.

HEDIS medical record reviews reflect the good care patients receive that cannot be captured via the claims process. We appreciate your commitment to providing high-quality care to our members, and look forward to working with you to complete this process.

Many of you will receive a letter from our President and CEO Patrick Conway clarifying Blue Cross NC’s reason for making these requests. The letter also outlines the expectations for these records. The letter states:

“All of our provider contracts contain language that requires the providers who join our network to supply Blue Cross NC, at no charge, with those medical records necessary to characterize the content of clinical encounters with our members and to allow Blue Cross NC to fulfill reporting requirements. These provisions create a contractual obligation on the part of a provider such as yourself to supply the records that Blue Cross NC will need and will be requesting in order to fulfill our HEDIS reporting requirements. As a result, Blue Cross NC expects the providers who enjoy the benefits of participation in our network to respond to the requests that we will be making for the records needed for our HEDIS reporting and provide the requested records at no charge.”

Early in February, we will provide you with the specific medical records we need. We’ll include the member’s name, dates of service, and measures selected for review, as well as instructions for submitting the medical records.

Please send all records within five business days of receiving a medical record request.

We want to minimize negative impacts on your office work flow, and the faster we obtain the necessary records, the fewer follow-up contacts will be necessary. Thank you, in advance, for your prompt response to our requests, and for helping us successfully complete our HEDIS reporting.