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Blue Choice

HEDIS

Healthcare Effectiveness Data and Information Set (HEDIS®)

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan participate in many national quality efforts including HEDIS. HEDIS is a tool that measures performance in the delivery of medical care and preventive health services. The National Committee for Quality Assurance (NCQA) coordinates and administers HEDIS yearly and the Centers for Medicare and Medicaid Services (CMS) uses it for monitoring the performance of health plans. The tool evaluates both physical and behavioral health clinical practice guideline (CPG) adherence.

HEDIS provides a consistent way to evaluate the quality of care you provide to our members. This allows employers, consumers and consultants a means of comparing health plans on an “apples-to-apples” basis. We use HEDIS to identify and acknowledge areas of excellence and opportunities for improvement. We also use HEDIS to develop quality initiatives and educational programs for members and providers.

The NCQA develops measures around conditions or services that impact a large portion of the population. Data is collected throughout the year through retrospective review of services via claims information and medical records. When you submit claims using complete and appropriate codes for these services, we are less likely to request medical records.

We recognize that the demands on providers are greater and more complex than ever before. Yet providing top quality care remains a principal priority. As your partner, we want to lend a hand in improving HEDIS scores. Our goal is to allow you to continue delivering the highest caliber care possible and in the process, ensure that we show the performance of our providers.

By honing in on key dimensions of care and services, HEDIS assists you in streamlining comprehensive, quality care that generates better health outcomes. Improving HEDIS scores is a win-win situation for all involved. Therefore, we’re offering our support by outlining the details of specific measures, identifying critical administrative steps and pointing you to valuable resources. 

Your continued participation and compliance with HEDIS ensures consumers and employers will see the superiority of our provider network.

Provider Reference Matrix

The matrix provides measure-specific information on what services are needed and how you can help improve our members’ overall health. The guide also includes the HEDIS Compliance Companion Forms. Complete the HEDIS Compliance Companion Forms to let us know when a member has already received the service or has a condition that excludes him or her from the measure. 

Medical Records

You may receive requests from us or one of our business partners to review medical charts for one or several of your patients. We appreciate your cooperation in helping us meet our quality goals as we seek to improve the overall health of our members — your patients.

We know it’s not an easy task to prepare charts for medical review. But we believe you are as committed to improving patients’ health outcomes as we are. So that’s why we are asking you to help us by complying with our requests for records.

We would also like you to talk with your vendors and encourage them to cooperate with requests they may receive on your behalf. As a participating provider, your contract states you agree to permit BlueCross, BlueChoice HealthPlan of South Carolina or one of our business partners to inspect, review and get copies of such records upon request at no charge. We appreciate you working with your vendors to ensure they understand this contractual arrangement to submit the requested records (on your behalf) without delay or request for payment.

If there is anything we can do to make this process easier for you, please let us know. We will do all we can to accommodate your request. We will even come to your office and collect the records if you want!

BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.