HEDIS Medical Record Review Requests

The National Committee for Quality Assurance (NCQA) and the U.S. Department of Health and Human Services (HHS) require an NCQA-certified auditor to perform an annual Healthcare Effectiveness Data and Information Set (HEDIS^®) audit of Blue Cross and Blue Shield of Texas’ (BCBSTX) health plan quality performance.

One or more of your patients may be randomly selected for medical record review as part of this process. While we use claims data to the extent possible, some of the measures require information from medical records.

Each measure requires precise documentation of services within the specified timeframes in order to meet HEDIS specifications. Therefore, it is important that health care practitioners follow the data collection instructions for each measure closely and provide BCBSTX or its contracted vendor, Enterprise Consulting Services, Inc. (ECS) with the medical record data requested.

For example, the Comprehensive Diabetes Care (CDC) is one measure that requires medical record data. For this measure, BCBSTX or its contracted representative will be requesting the information as described below for a random sample of our members/subscribers who have been identified with diabetes diagnoses.

HbA1c:

• Identify the last HbA1c date of service and value in 2015.
  • Look for a notation of “HbA1c,” “A1c,” “HgbA1c,” “Glycohemoglobin A1c” or “Hemoglobin A1c.”

Retinal Eye Exam:

• Identify if the members/subscribers had a retinal eye exam in 2014 or 2015.
• To identify a retinal eye exam, look for reference to “fundus,” “macula,” “retina,” “dilation of the eye (dilating agents),” etc.
  • The eye exam must be with an eye care professional. Therefore, the specialty of the provider for the eye exam must be written on the medical record.
• If the medical record contains documentation of a retinal exam by an eye care professional in 2015, no results are needed. If the retinal eye exam was performed in 2014, include the result of the retinal or dilated eye exam.
• A negative eye exam may be recorded as: “No background diabetic retinopathy (BDR)” or “No evidence of diabetic retinopathy (DR).”
• For a positive eye exam, results may be recorded as: “DR,” “BDR,” “proliferative diabetic retinopathy (PDR)” or “non-proliferative diabetic retinopathy (NPDR).”

Blood Pressure:

• Identify the last blood pressure in the medical record in 2015.
• Do not submit blood pressure readings from inpatient stays or outpatient visits where a diagnostic test or surgical procedure was performed. Also, blood pressure readings reported or taken by the member/subscriber should not be submitted.

Medical Attention for Nephropathy:

• Identify evidence in the medical record of medical attention for nephropathy. This may include:
• Documentation of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blockers (ARBs) therapy during 2015;
• Documentation of a visit to a nephrologist in 2015;
• Documentation of a diagnosis of nephropathy, end-stage renal disease (ESRD), chronic renal failure (CRF), acute renal failure (ARF), renal insufficiency, dialysis, or renal transplant in 2015; and/or
• A urine test for albumin or protein with results.

If applicable, you will receive a letter outlining the information that is being requested, the medical record request list with members’/subscribers’ names and the identified measures that will be reviewed. If you have any questions about medical record requests, please contact the BCBSTX HEDIS Department at 972-766-6614.

We at BCBSTX thank you for your assistance with this very important health plan quality improvement initiative!

HEDIS is a registered trademark of NCQA

ECS is an independent third party vendor that is solely responsible for the products or services it offers. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third-party vendors. If you have any questions regarding the services they offer, you should contact the vendor(s) directly.