Effective for claims processed on or after December 1, 2023, the editing systems at Anthem Blue Cross and Blue Shield will be updated to align with the American Medical Association (AMA) CPT^® Manual, HPCPS Level II Manual, and Centers for Medicare & Medicaid Services (CMS) correct coding guidelines, for the following services:

• Ulcer debridement and ulcer staging:

  • According to the ICD-10 Diagnosis Coding Manual, specific diagnosis codes that reflect the stage of the ulcer should be billed with the appropriate CPT code. For example, if billing a stage 3 pressure ulcer code, a stage 4 diagnosis code should not be reported.
  • According to the AMA CPT Manual, a debridement of an ulcer should be reported with the appropriate diagnosis code that reflects that service.

• Billing of anatomical modifiers:

  • According to the AMA CPT and HCPCS Level II manuals, the appropriate anatomical modifier is required to be appended to the appropriate procedure code. If not, the claim line will be denied. These modifiers designate the body part that a service is being performed on (for example, FA: Left hand, thumb, TA: Left foot, great toe).

• Billing of interprofessional telephone/internet consultations:

  • These billed procedure codes will follow the AMA CPT Manual coding guidelines.

Claim lines not billed in accordance with the correct coding guidance outlined above will be denied.

If you disagree with a claim reimbursement decision, please follow the claim dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

With your help, we can continually build towards a future of shared success.

In 2024, the annual PCP Access Studies Office Level Survey will be performed by a new vendor, the Center for the Study of Services (CSS). The purpose of this survey is to assess adequate appointment wait times for our members with an urgent condition or for routine services. The survey will be conducted in the same manner as in the past, and your cooperation is expected and appreciated. Kindly notify office staff of the requirement to participate in this survey.

Keeping your data up to date is a condition of your provider contract with Anthem Blue Cross and Blue Shield (Anthem) and a requirement as part of the Consolidated Appropriations Act (CAA). We ask that you update office information using the PDM application on the Availity Essentials platform and that you participate in quality programs such as this critical survey.

Office information crucial for the survey includes:

• Having correct, working phone numbers.
• Updating information such as when a practitioner has moved, retired, or is deceased.
• Updating if your practice is no longer contracted with Anthem, accepts private pay only, or is no longer in business.

You are also required to provide compliant after-hours, 24/7, urgent care messaging, instructing the caller/patient to hang up and call 911 or go to urgent care or emergency room (ER) or you must directly connect the caller with PCP or on-call physician.

Your contract compels access for all covered members to obtain timely needed appointments. The leading timeframes are below.

The annual behavioral health access studies will see a change in 2024 as a new vendor, Center for the Study of Services (CSS) in Washington, D.C., will be performing the office level survey and making calls during the first through third quarters. The survey will be conducted in the same manner as in the past and your cooperation is expected and appreciated. The purpose is to assess adequate appointment wait times for our members with an urgent condition or for routine services.

Consequently, we ask that you update office information using the PDM application on Availity Essentials or follow processes if assigned to Carelon Behavioral Health, Inc., and that you participate in quality programs, such as this critical survey, as a condition of your contract. The main challenges the vendor encounters are incorrect or non-working phone numbers; practitioner moved, retired, or is deceased; the practice has left their Anthem Blue Cross and Blue Shield (Anthem) contract, accepts private pay only, or is no longer in practice; and staff refusing to participate in the survey. Please take time to update information for each practitioner associated with the practice phone number(s), past or present.

Your contract compels access for all covered individuals to obtain timely needed appointments. The leading timeframes are below. See your Anthem Provider Manual for details. And don’t forget your compliant after-hours emergency or urgent messaging 24/7, by a recording or a live person, instructing the caller/patient to hang up and call 911 or 24-hour crisis services, or go to urgent care or ER; or directly connecting with practitioner or on-call practitioner.

Nevada behavioral healthcare appointment access

We are committed to helping patients more easily access the care they need.

As a reminder, we will update our claim editing software for outpatient facility services throughout 2024, with many updates occurring quarterly. These updates include, but are not limited to:

• The addition of new and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers, revenue codes) and associated edits.
• Updates related to the appropriate use of various code combinations, including but not limited to, CPT/HCPCS code to revenue code, type of bill to procedure code, type of bill to CPT/HCPCS code, and CPT/HCPCS code to modifier.
• Updates to National Correct Coding Initiative edits (NCCI) and facility outpatient hospital services medically unlikely edits (MUEs).
• Updates to reflect coding requirements as designated by industry standard sources such as the National Uniform Billing Committee (NUBC) and the Centers for Medicare and Medicaid Services (CMS).

As a reminder, we will update our claim editing software for professional services throughout 2024, with most updates occurring quarterly. These updates apply to any provider, provider group (identified by tax identification number), and/or across providers and claim type (such as, professional or facility) and include, but are not limited to:

• The addition of new, and revised codes (for example, CPT^®, HCPCS, ICD-10, modifiers) and associated edits such as:
  • ICD-10 laterality
  • Add-on procedures (indicated by + sign)
  • Code book parenthetical statements and other directives about appropriate code use (for example, separate procedure, do not report, list separately in addition to, etc.)
• Updates to editing for multiple procedure and bilateral reduction calculations based on relative value unit (RVU) as designated and updated by the Centers for Medicare & Medicaid (CMS) in the physician fee schedule relative value (PFSRV) files
• Updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
• Updates to incidental, mutually exclusive, and unbundled (re-bundle) edits
• Updates to code edits associated with reimbursement policies including, but not limited to, bundled services, global surgery preoperative, and post-operative periods assigned by CMS, edits that allow/disallow for assistant surgeon/co-surgeon/team surgeon, and frequency edits.

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service, or care. Nor, do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization. Anthem Blue Cross and Blue Shield’s (Anthem) medical policies are available on Anthem’s website at Anthem.com.

Refer to attachment to view full details

The National Committee on Quality Assurance (NCQA) has advised Durable Medical Equipment (DME) providers are to be considered within the scope of an entity’s credentialing program for accreditation purposes. Starting February 2024, recredentialing of the existing Durable Medical Equipment Providers and Prosthetic and Orthotic Suppliers (DMEPOS) network will begin. You will receive communication asking you to either complete an application or to supply us with any of the following information:

• Copy of all federal, state, and/or local licenses required to operate as a healthcare facility (by location).

• Copy of accreditation certificate or letters if accredited.
• Copy of most recent CMS or state survey (with deficiencies) including cover letter from CMS or state agency stating facility is in substantial compliance or Corrective Action Plan if deficiencies were cited if not accredited is required.

Please respond to these communications as quickly as possible so no disruption in service to our members or to you occurs. Contact information for questions related to this change will be included in the outreach sent.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare. The Credentialing team looks forward to working with you.

What if I need assistance?

Managing any illness can be a difficult thing to do. Knowing who to contact, what test results mean, or how to get needed resources is very important and can be overwhelming.

Anthem Blue Cross and Blue Shield (Anthem) is available to help with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and professionals that are there to support members, families, primary care physicians, behavioral health (BH) practitioners, and caregivers. The case management process uses the experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient healthcare.

For physical health services, members or caregivers can refer themselves or family members by calling the number located below. They will be transferred to a team member based on the immediate need. Physicians can also refer their patients by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

For BH or substance use disorder services members can contact their health plan to verify benefits and access Anthem.com, or if an FEP member, fepblue.com to search for and access BH providers. It is best to have the member or member’s family contact our department directly to ensure privacy.

How do you contact us?

For commercial and exchange members, the member can contact customer service for assistance.

For FEP members, physical and behavioral health practitioners can refer to Anthem behavioral health case management with member consent by calling 800-711-2225 option 3.

Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment, and referral. Anthem Blue Cross and Blue Shield (Anthem) would like to take this opportunity to stress the importance of communicating with your patient’s other healthcare practitioners. This includes primary care physicians (PCPs) and medical specialists, as well as behavioral health practitioners (BH).

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a BH specialist by another healthcare practitioner. Anthem urges all of its practitioners to obtain the appropriate permission from these patients to coordinate care between BH and other healthcare practitioners at the time treatment begins. We expect all healthcare practitioners to:

• Discuss with the patient the importance of communicating with other treating practitioners.
• Obtain a signed release from the patient and file a copy in the medical record:
  • Document in the medical record if the patient refuses to sign a release.
• Document in the medical record if you request a consultation.
• If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.
• Document evidence of clinical feedback (in other words, consultation report) that includes, but is not limited to:
  • Diagnosis
  • Treatment plan
  • Referrals
  • Psychopharmacological medication (as applicable)

To facilitate coordination of care, we have several tools available on our Provider website for BH and other medical practitioners including:

• Coordination of Care Form
• Coordination of Care Letter Template - Behavioral Health
• Coordination of Care Letter Template - Medical

The following behavioral health forms, brochures, and screening tools for substance use and attention-deficit/hyperactivity disorder (ADHD) are also available on our Provider website:

• Alcohol Use Assessment Brochure
• Antidepressant Medication Management
• Edinburgh Postnatal Depression Scale
• Opioid Use Assessment Brochure
• Substance Brief Intervention/Referral Tool (SBIRT)
• Vanderbilt ADHD Diagnostic Parent Rating Scale

We ask that you review your online provider directory information on a regular basis to ensure it is accurate. Access your information by visiting anthem.com/provider, then select the Find Care button at the top right of the webpage.

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. We will send you an email acknowledging receipt of your request. Online update options include:

• Add/change an address location
• Name change
• Phone/fax number change
• Provider leaving a group or a single location
• Closing a practice location

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Reviewing your information on a regular basis is the best way to help ensure your online provider directory information is current.

With your help, we can continually build towards a future of shared success.

As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our quality programs, are based on reasonable medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances, and recent medical research.

All guidelines are reviewed annually and updated as needed. The current guidelines are available on our website at https://www.anthem.com/provider/ and select Change State >Provider > Select Policies, Guidelines & Manuals under Provider Resources> scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

If you have questions, please contact the number on the back of the member ID card for Provider Services.

The delivery of quality healthcare requires cooperation between patients, their providers, and their healthcare benefit plans. One of the first steps is for patients and providers to understand their rights and responsibilities. Therefore, in line with our commitment to involve the health plan, participating practitioners, and members in our system, Anthem Blue Cross and Blue Shield has adopted a Members’ Rights and Responsibilities statement.

This statement can be found on our website under the FAQ question about Laws and Rights that Protect You. To access the statement, visit anthem.com and select Provider. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state and scroll down to Member Rights and Responsibilities under More Resources. Then select the Read about member rights link. For federal employees, practitioners may access the FEP member portal at www.fepblue.org/memberrights to view the FEPDO Member Rights Statement.

As a contracted provider for special needs plan (SNP) from Anthem Blue Cross (Anthem), you are required to participate in an annual model of care training for providers per CMS regulations. This training includes a detailed overview of Anthem special needs plans and program information — highlighting cost sharing, data sharing, participation in the Interdisciplinary Care team (ICT), where to access the member’s health risk assessment results, plan of care, and benefit coordination. Please remember this training is specific to our plans and delivery of care for members ensuring their specific care needs are met. Your participation is critical for improved quality and health outcomes.

Training for SNP product for Anthem is self-paced and available at availity.com.

The training must be completed by December 31, 2023.

How to access the Custom Learning Center on the Availity Essentials website:

1. Log in to Availity Essentials website at availity.com:
   • At the top of Availity Essentials website, select Payer Spaces and select the appropriate payer.
2. On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
3. In the Custom Learning Center, select Required Training.
4. Select Special Needs Plan and Model of Care Overview.
5. Select Enroll.
6. Select Start.
7. Once the course is completed, select Begin Attestation and complete.

Not registered for Availity Essentials?

Have your organization’s designated administrator register your organization for the Availity Essentials website:

1. Visit availity.com to register.
2. Select Register.
3. Select your organization type.
4. In the Registration wizard, follow the prompts to complete the registration for your organization.

Refer to these PDF documents: https://apps.availity.com/availity/Demos/Registration/index.htm for complete registration instructions.

Anthem Blue Cross and Blue Shield (Anthem) and our subsidiary company, HMO Nevada, are pleased to provide you with our updated and new Medical Policies. Anthem will also be implementing changes to our Clinical Utilization Management (UM) Guidelines that are adopted for Nevada. The Clinical UM Guidelines published on our website represent the Clinical UM Guidelines currently available to all plans for adoption throughout our organization. Because local practice patterns, claims systems and benefit designs vary, a local plan may choose whether to implement a particular Clinical UM Guideline. The link below can be used to confirm whether the local Plan has adopted the Clinical UM Guideline(s) in question. Adoption lists are created and maintained solely by each local plan.

The major new policies and changes are summarized below. Please refer to the specific policy for coding, language, and rationale updates and changes that are not summarized in the attachment.

Anthem Blue Cross and Blue Shield (Anthem) is excited to announce a new High Performing Provider (HPP) designation to care providers meeting certain cost and quality metrics. Through this new designation, Anthem is expanding our consumer tools and content to assist members in making more informed and personalized healthcare decisions. Initially, the designation will focus on certain types of professional providers, but it may be broadened to include other care provider types in the future.

The High Performing Provider designation will launch on January 1, 2024.

Anthem may highlight HPPs in various ways, including, but not limited to:

• Special opportunities to participate in product offerings.
• When members contact Anthem with requests for referral options.
• Placing a designation in Anthem’s Care and Cost Finder. This would be in addition to Anthem’s existing tool in Care and Cost Finder called Personalized Match that provides Anthem members with the option to search for in-network care providers through a specialized sorting tool that considers certain cost and quality metrics, as well.

For more information on the HPP designation, you can view the designation methodology, or to know if your practice will receive the designation, send an email to HPPdesignation@anthem.com.

Measure description

The percentage of discharges for members 18 years of age and older who had each of the following:

• Notification of inpatient admission (can only be captured through medical record review)
• Receipt of discharge information (can only be captured through medical record review)
• Patient engagement
• Medication reconciliation post-discharge

What we are looking for in care provider records:

• Notification of inpatient admission — documentation in the outpatient medical record must include evidence of receipt for notification of inpatient admission on the day of admission through two days after the admission (three total days) with evidence of the date when the documentation was received. Any of the following examples meet criteria:
  • Communication about admission between inpatient care providers or ER and the member’s PCP or ongoing care provider (for example, phone call, e-mail, fax, information exchange, automated alert system, shared electronic medical record, or from the member’s health plan)
  • Indication that the PCP or ongoing care provider admitted the member to the hospital
  • Indication that a specialist admitted the member to the hospital and notified the member’s PCP or ongoing care provider
  • Indication that the PCP or ongoing care provider placed orders for tests and treatments any time during the member’s inpatient stay
  • Documentation that the PCP or ongoing care provider performed a preadmission exam or received communication about a planned inpatient admission. The time frame that the preadmission exam or planned inpatient admission must be communicated is not limited to the day of admission through two days after the admission (three total days)
• Receipt of discharge information — documentation in the outpatient medical record must include evidence of receipt of discharge information on the day of discharge through two days after the discharge (three total days) with evidence of the date when the documentation was received. Discharge information may be included in, but not limited to, a discharge summary or summary of care record, or in the structured fields in an electronic health record. At a minimum, the discharge information must include the following:
  • The practitioner responsible for the member’s care during the inpatient stay
  • Procedures or treatments provided
  • Diagnoses at discharge
  • Current medication list
  • Testing results, or documentation of pending tests or no tests pending
  • Instructions for patient care post-discharge
• Patient engagement — documentation in the outpatient medical record must include evidence of patient engagement within 30 days after discharge. Any of the following meet criteria:
  • An outpatient visit, including office visits and home visits
  • A telephone visit
  • A synchronous telehealth visit where real-time interaction occurred between the member and care provider using audio and video communication
  • An e-visit or virtual check-in (asynchronous telehealth where two-way interaction, which was not real-time, occurred between the member and care provider)
• Medication reconciliation — documentation in the outpatient medical record must include evidence of medication reconciliation and the date when it was performed. Medication reconciliation must be conducted by a prescribing practitioner, clinical pharmacist, physician assistant, or registered nurse. Any of the following meet criteria:
  • Documentation of the current medications with a notation that the care provider reconciled the current and discharge medications
  • Documentation of the current medications with a notation that references the discharge medications (for example, no changes in medications since discharge, same medication at discharge, discontinue all discharge medications)
  • Documentation of the member’s current medications with a notation that the discharge medications were reviewed
  • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
  • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review:
    • Evidence that the member was seen for post-discharge follow-up requires documentation that indicates the care provider was aware of the member’s hospitalization or discharge
  • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
  • Notation that no medications were prescribed or ordered upon discharge
• Exclusions:
  • Evidence of hospice or palliative services in 2023

• Evidence patient expired in 2023

Helpful hints:

• Documentation of a procedure/surgery that is typically performed inpatient (such as, aortic bypass) does not indicate that the care provider is aware of the hospitalization. Documentation of post-op/surgery follow-up alone does not indicate the care provider was aware of the hospitalization or discharge. Make sure documentation references the hospitalization, admission, or inpatient stay.
• If performing a pre-admission exam, document that it is a pre-admission exam.
• If performing a pre-surgical, pre-operative, or surgical clearance exam, the date of the admission must be documented.

• Implement process to receive automated alerts when a member is admitted or discharged from an inpatient facility.
• Review discharge medications with the member.

• Schedule post-hospital discharge following appointments and have the office call the member to remind them.
• Document a received date for discharge summaries and notification of inpatient admissions.

• Use the appropriate billing codes for Medication Reconciliation and Patient Engagement.

Healthcare Effectiveness Data Information Set (HEDIS^®) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS 2023 documentation for Childhood Immunization Status (CIS) Measure description:

The percentage of children 2 years of age in the measurement year who had the following on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three Hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One Hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS 2023 documentation for Immunizations for Adolescents (IMA) Measure description: The percentage of adolescents 13 years of age in the measurement year who had the following:

• One MenACWY (meningococcal)
• One Tdap (tetanus, diphtheria toxoids and acellular pertussis)
• Two or three HPV (human papillomavirus)

The measure calculates a rate for each vaccine and two combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC) Measure description: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday

What we are looking for in provider medical records:

• Immunization records from birth (Department of Health immunization records are acceptable)
• If available, newborn inpatient records documenting Hep B
• For those immunizations not recorded on the immunization record, provide progress notes for: Immunizations administered, patient’s history of disease (chickenpox, Hep A, Hep B, measles, mumps, rubella)
• Anaphylaxis due to the Dtap, IPV, MMR, HIB, Hep B, VZV, PCV, Hep A, RV, or Influenza vaccines
• Encephalitis due to the Dtap vaccine
• Diagnosis of severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or intussusception
• Meningococcal vaccine with a date of service on or between the member’s 11th and 13th birthdays
• Tdap vaccine with a date of service on or between the member’s 10th and 13th birthdays
• At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart, or at least three HPV vaccines with different dates of service on or between the member’s ninth and 13th birthdays
• Lead testing results and date (capillary or venous) on or before the child’s second birthday
• Evidence of hospice services in 2023
• Evidence patient expired in 2023

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by the child’s second birthday.
• Assess immunization needs at every clinical encounter, including sick visits and when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given, including hospitals, health departments, all former providers, include refusals, and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination; however, it must be given on the child’s second birthday to be compliant.

Instead of submitting medical records for the HEDIS^® hybrid project, use the Remote Electronic Medical Record (EMR) Access Service provided by Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem). We offer providers the ability to grant access to your EMR system directly to pull the required documentation to aid your office in reaching compliance. Granting our team remote access to your EMR helps reduce the time and costs associated with medical record retrieval while improving efficiency and allowing your office to focus on patient care.

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:

• We only access medical records of members pulled into the HEDIS sample using specific demographic data.
• We only retrieve the medical records that have claims evidence related to the HEDIS measures.
• We only access the least amount of information needed for a use, disclosure, or a request.
• We only save to file and do not physically print any PHI.

Getting started with Remote EMR Access is just one email away. Email Centralized_EMR_Team@anthem.com today. To learn more about our Remote EMR Access, view the frequently asked questions below. 

Q. How do you retrieve our medical records?

A. We access your EMR using a secure website and retrieve only the necessary documentation by printing it to an electronic file we store internally, on our secure network drives.

Q. Is this process secure?

A. Yes, we only use secure internal resources to access your EMR systems. All retrieved records are stored on Anthem secure network drives.

Q. Why does Anthem need full access to the entire medical record?

A. There are several reasons we need to look at the entire medical record of a member, including:

• HEDIS measures can include up to a 10-year look back of a member’s information.
• Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
• Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents.

Q. What information do I need to submit to use your Remote EMR Access Service?

A. Email Centralized_EMR_Team@anthem.com with the following information:

Practice/facility demographic information (for example, address, National Provider ID, Taxpayer Identification Numbers, etc.)

• EMR system information (for example, type of EMR system, required access forms, access type, etc.)
• List of current providers/locations or a website for accessing this list.

HEDIS^® measure data is collected by one or more methods:

• Administrative method — claims and supplemental data
• Hybrid method — administrative and medical record data
• Survey method — Health Outcomes Survey(HOS) & Consumer Assessment of Healthcare Providers & Systems (CAHPS^®)
• Electronic Clinical Data Systems (ECDS) — HEDIS reporting standard that leverages electronic data from multiple sources. See below.

The HEDIS Electronic Clinical Data Systems (ECDS) Reporting Standard was introduced in HEDIS 2016 (measurement year 2015) by the National Committee of Quality Assurance (NCQA) and encourages health information exchange, which is the secure sharing of patient medical information electronically. ECDS data collection is part of NCQA’s nationwide plan to capture information regarding aspects of care quality with less reliance on clinical medical record review.

There are four types of ECDS:

1. Electronic Health Record (EHR)/Personal Health Record (PHR): Real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs eligible for this category of ECDS reporting include the NCQA eMeasure certification program or any system that meets the 2015 Edition Base Electronic Health Record (EHR) definition.
2. Health Information Exchange (HIE)/Clinical Registry: HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives. Doctors, nurses, pharmacists, other health care providers and patients can use HIEs to access and share vital medical information, with the goal of creating a complete patient record. Clinical registries can be sponsored by a government agency, nonprofit organization, health care facility or private company, and decisions regarding use of the data in the registry are the responsibility of the registry’s governing committee.
3. Case Management System: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. Case management systems eligible for this category of ECDS reporting include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
4. Administrative: Includes data from administrative claim processing systems for all services incurred (in other words, paid, suspended, pending and denied) during the period defined by each measure’s participation as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.

Having more time to focus on patient care rather than responding to medical record requests is possible by participating in Electronic Clinical Data Systems (ECDS). We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Let us help by granting EMR Direct Remote access to our EMR team.

Need more information or ready to sign up?

Please email us today at: Centralized_EMR_Team@unicare.com.

HEDIS^® measure data is collected by one or more methods:

• Administrative method — claims and supplemental data
• Hybrid method — administrative and medical record data
• Survey method — Health Outcomes Survey(HOS) & Consumer Assessment of Healthcare Providers & Systems (CAHPS^®)
• Electronic Clinical Data Systems (ECDS) — HEDIS reporting standard that leverages electronic data from multiple sources. See below.

The HEDIS Electronic Clinical Data Systems (ECDS) Reporting Standard was introduced in HEDIS 2016 (measurement year 2015) by the National Committee of Quality Assurance (NCQA) and encourages health information exchange, which is the secure sharing of patient medical information electronically. ECDS data collection is part of NCQA’s nationwide plan to capture information regarding aspects of care quality with less reliance on clinical medical record review.

There are four types of ECDS:

1. Electronic Health Record (EHR)/Personal Health Record (PHR): Real-time, patient-centered records that make information available instantly and securely to authorized users. EHRs eligible for this category of ECDS reporting include the NCQA eMeasure certification program or any system that meets the 2015 Edition Base Electronic Health Record (EHR) definition.
2. Health Information Exchange (HIE)/Clinical Registry: HIEs and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives. Doctors, nurses, pharmacists, other health care providers and patients can use HIEs to access and share vital medical information, with the goal of creating a complete patient record. Clinical registries can be sponsored by a government agency, nonprofit organization, health care facility or private company, and decisions regarding use of the data in the registry are the responsibility of the registry’s governing committee.
3. Case Management System: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. Case management systems eligible for this category of ECDS reporting include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
4. Administrative: Includes data from administrative claim processing systems for all services incurred (in other words, paid, suspended, pending and denied) during the period defined by each measure’s participation as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files, and member call service databases.

Having more time to focus on patient care rather than responding to medical record requests is possible by participating in Electronic Clinical Data Systems (ECDS). We are focused on reducing administrative burdens, so you can do what you do best – care for our members. Let us help by granting EMR Direct Remote access to our EMR team.

Need more information or ready to sign up?

Please email us today at: Centralized_EMR_Team@unicare.com.