In addition to the annual HEDIS® medical record review, the Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) quality management group conducts ambulatory medical record reviews (AMRR) for compliance with federal, state, accreditation standards and contractual requirements including but not limited to:
  • Adherence to Clinical Practice Guidelines
  • National Committee for Quality Assurance and HEDIS criteria
  • Nevada Division of Health Care Financing and Policy
  • Early and Periodic Screening, Diagnostic and Treatment (also known as the Nevada Healthy Kids program)

 

Please refer to the Program Participating Provider Agreement Sections 3.7; 3.9; 4.2 second paragraph;

6.15 (ii); 7.1 for contractual information; and the Provider ManualQuality Management Section 10.1 AMRR details.

 

Ongoing review allows for evaluation and improvements of providers, practices and overall network performance. Anthem clinical quality management nurses will call to schedule an appointment and confirm contact and location information. A list of the members selected for review will be sent via secure fax/email or established SFTP site to help prepare for the medical record review. Once the review is completed, an exit interview will be performed with the provider or practice manager. The results and opportunities for improvement will be sent within three days of the audit to the provider site.

 

Anthem will conduct a re-audit in six months for providers who score less than 80% to monitor progress towards improvement and those who require a corrective action plan for deficiencies. If the overall score remains below 80% on re-audit, the findings will be presented to the plan’s medical director for further action.

 

If you have any questions regarding your AMRR or its findings, you may contact me directly at 702-228-1308.

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

 

ANV-NU-0119-20 April 2020



Featured In:
June 2020 Anthem Provider News and Important Updates -- Nevada