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January 2014

Risk adjustment, HEDIS® medical record reviews begin in January

As the New Year begins, physician office staffs should monitor their mail for patient medical record requests.

Verisk Health has been selected by Blue Cross Blue Shield Association to gather medical records for review on behalf of Blue Cross and Blue Shield companies nationwide. Blue plans are using Verisk to retrieve medical records for members — or from providers in other plans’ service areas — to support risk adjustment, Healthcare Effectiveness Data and Information Set measures and government requirements related to the Affordable Care Act.

Keep in mind that the medical record reviews are in addition to the risk adjustment and HEDIS medical record review processes performed by Inovalon on behalf of BCBSM.

Effective medical record retrieval services play a fundamental role in driving optimal quality reporting outcomes and ensuring appropriate risk scores — all of which contribute to enhanced health care delivery and affordability. Health plans are also required by the Department of Health and Human Services to accurately report members’ health conditions. HHS will be auditing the plans’ reported conditions.

As outlined in your Medicare Plus BlueSM PPO manual, please respond to these medical record requests within the requested timeframe. Verisk Health is contractually bound to preserve the confidentiality of health plan members’ protected health information obtained from medical records, in accordance with HIPAA regulations.

Patient-authorized information releases are not required in order for you to comply with these requests for medical records when both the provider and health plan had a relationship with the patient and the information relates to the relationship. For more information regarding privacy rules, please visit hhs.gov/ocr/privacy**.

If you have any questions about the medical record requests, you may contact Verisk Health at 1-877-489-8437.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

**BCBSM does not control this website or endorse its general content.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.