HEDIS® and HEDIS Record Requests


South Carolina Medicaid managed care organizations (MCOs) request medical records from providers to comply with the requirements the South Carolina Department of Health and Human Services (SCDHHS) has for reporting Healthcare Effectiveness Data and Information Set (HEDIS®). Please cooperate with the MCOs' medical record requests and ensure that any medical record vendors do so as well, and/or provide the means through which an MCO may access medical records of Medicaid members. Generally, access to medical records is included in network contracts. Should you elect to use a medical record vendor, potential delays and duplicate requests may be avoided by reviewing your vendor's process for addressing outstanding medical records requests or complaints between the MCO and the vendor to see that their process is adequate to protect your compliance with your network contract. The requesting MCO will provide their own contact information for submitting medical records in response to their request.

Reducing the Number of Medical Record Requests
MCOs must pursue medical records in instances where they do not have the claim codes that provide evidence that members received recommended care. Claim codes are what MCOs check first, before making a medical records request. Therefore, the biggest opportunity to reduce the number of medical records requests you receive is to use and submit all applicable, appropriate codes when evaluating patients throughout the year. For help understanding what codes to use that document compliance with HEDIS measures, consult MCOs' quality websites and/or departments for codes that correspond to HEDIS measures.

HEDIS is a quality function, and the U.S. Department of Health and Human Services (HHS) affirms that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule permits a provider to disclose protected health information to a patient's health plan for HEDIS. For more information, please visit hhs.gov

Why HEDIS Matters to You - A Look to the Future
More and more payers in all lines of business (for example, Medicare and Medicaid) are tying dollars to performance on quality measures, including HEDIS. HEDIS rates can have a big impact on your patients, the perception of the care you provide and even your bottom line. So, take every opportunity now to get ahead on HEDIS improvement.

Your Feedback
What are the challenges that you face as a practitioner or an office manager in meeting HEDIS needs? Are there other HEDIS compliance issues that you think SCDHHS should know about? SCDHHS is interested in learning how it can better improve the HEDIS program, which in turn improves health and reduces costs to the health system. Please email the SCDHHS Quality Division at quality@scdhhs.gov to provide feedback.

Medicaid MCOs' quality departments are also a source for HEDIS questions and HEDIS specifications and compliant codes.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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