Quality Guidelines

Patient health and safety is essential in creating quality health care. We support industry standards to ensure top quality care is delivered to our members. Below are information and tools to help physicians and other health care professionals in supporting this need for optimal care.

Clinical Guidelines

Healthcare Effectiveness Data and Information Set (HEDIS®)

Healthcare Effectiveness Data and Information Set (HEDIS®) is a performance measurement tool that is coordinated and administered by NCQA (National Committee for Quality Assurance) and used by the Centers for Medicare & Medicaid Services (CMS) for monitoring the performance of health plans. HEDIS® consists of a set of performance measures utilized by more than 90 percent of American health plans which compares how well a plan performs in these areas:

  • Quality of care
  • Access to care
  • Member satisfaction with the health plan and doctors
Why is HEDIS® important?

HEDIS® results are used to measure performance, identify quality initiatives and provide educational programs for providers and members. HEDIS® ensures health plans are offering quality preventive care and service to members. It also allows for a true comparison of the performance of health plans by consumers and employers.

What is the value of HEDIS® to health care professionals?

HEDIS® can help save you time while also potentially reducing health care costs. By proactively managing patients’ care, you are able to effectively monitor their health, prevent further complications and identify issues that may arise with their care. Monitoring these measures can help you:

  • Identify noncompliant members to ensure they receive preventive screenings
  • Understand how you compare with other Plan providers as well as with the national average
What is your role in HEDIS®?

You play a central role in promoting the health of our members. You and your office staff can help facilitate the HEDIS® process improvement by:

  • Providing the appropriate care within the designated time frames
  • Documenting all care in the patient’s medical record
  • Accurately coding all claims
  • Responding to our requests for medical records within 5-7 days

The records you provide us during this process help us to validate the quality of care provided to our members. We appreciate your cooperation and timeliness in submitting the requested medical record information.

Medical Records

You may receive requests from us or one of our vendors to review medical charts for one or several of your patients. We appreciate your cooperation in helping us meet our quality goals as we seek to improve the overall health of our members—your patients. We know it's not an easy task to prepare charts for medical review, but we believe you are as committed to improving patients' health outcomes as we are. That's why we are asking you to help us by complying with our requests for records. We would also like you to talk with your vendors and encourage them to cooperate with requests they may receive on your behalf. As a participating provider, your contract states you agree to permit Blue Cross and Blue Shield of Nebraska or one of our business partners to inspect, review and obtain copies of such records upon request at no charge. We appreciate you working with your vendors to ensure they understand this contractual arrangement to submit the requested records (on your behalf) without delay or request for payment. If there is anything we can do to make this process easier for you, please let us know. We will do all we can to accommodate you.

More information on HEDIS (ncqa.org)