This communication applies to Commercial and Medicare Advantage plans from Anthem Blue Cross and Blue Shield (Anthem).


The Statin Therapy Exclusions for Patients With Cardiovascular Disease (SPC) HEDIS® measures examines the percentage of patients with atherosclerotic cardiovascular disease (SPC) who received and adhered to statin therapy throughout the measurement year. However, statin therapy does not work for everyone, and alternative therapies are necessary to minimize their risk for future complications. If you have patients who cannot tolerate statin therapy, it is important that you document and notify us annually so we can exclude the patients from your list of open care gaps. Refer to NCQA guidelines for a complete listing of exclusion criteria.


How to submit exclusion data:

  • Indicate the appropriate ICD-10 code for encounters.
  • Use standard data file submission or EMR/EHR access for supplemental data collection.


Exclusions are applied based on diagnosis codes on the date of service provided on the claim or through supplemental data collection. Based on the timing of your data submission and when reports are generated, it may take several weeks for exclusions to be reflected on your reports.


Please note, if exclusions are not coded properly or given to Anthem Blue Cross and Blue Shield in the proper format, the care gap will remain open until the failure reason is corrected. Patients listed on the open care gap report are assumed to tolerate statin therapy and will have their care gaps closed after claims for moderate to high intensity statins are adjudicated by Anthem.


Tips for implementing best practices and improving your quality scores:

  • Educate your patients on the importance of adhering to their statin therapy regime and on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
  • Statin therapy should also be accompanied by lifestyle modifications, such as a healthy diet and exercise. Work with your patients to proactively identify and overcome any barriers that may prevent lifestyle modifications. Discuss creating a realistic, individualized exercise routine based on the patient’s ability and interests. Encourage a healthy diet based on the patient’s culture and locally available produce, stores, and resources.


If you have any questions or concerns about Anthem Blue Cross and Blue Shield you can contact the phone number on the back of the member’s ID card for Provider Services.

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

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March 2023 Anthem Provider News - New Hampshire