Healthcare Effectiveness Data and Information Set (HEDIS®)

WHAT IS HEDIS®?

HEDIS® (Healthcare Effectiveness Data and Information Set) 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 HEDIS® IS 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.

VALUE OF HEDIS® TO YOU, OUR PROVIDERS

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 HEDIS® 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.

Watch for additional HEDIS® information in upcoming Update editions!

For more information on HEDIS®, visit https://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx.

Complete the Obstetrical Needs Assessment Form (ONAF) to let us know about any gaps in care you may closed.

Doing so allows us to:

  • Target our outreach to members who may need specific health services
  • Reduce the number of record requests you receive during the annual HEDIS effectiveness of care audit


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. So 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.  

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.