February 7, 2019
HEDIS is a set of quality measures 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.
How are we involved?
Medical records from our members’ physicians are required to compile the necessary data for some of the HEDIS measures. Reporting HEDIS® measures is also required for our participation in the Affordable Care Act’s Health Insurance Marketplace, formerly known as the Exchange.
What to expect
NCQA limits all health plan medical record collection to a set period from February to early May. Medical records for one or more of your patients may be identified for review during those months, and you may be contacted by our partner COTIVITI. You may submit 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 if you if the submitted records are incomplete, illegible, or otherwise unclear.
Patient 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 to us (or to COTIVITI) any medical record information related to psychotherapy, HIV, substance abuse, or genetic testing—and we won’t request this information either.
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. A provider may disclose protected health information to a health plan for the plan’s 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 regarding the retrieval of medical records and the HEDIS data collection process, contact your network contract specialist, or the Premera Network Relations Department at (425) 918-4000, (509) 252-7460, or (800) 722-1471.
Thank you for your participation in HEDIS and for your collaboration in improving quality of care.