Date: March 15, 2019
To: All Medical Assistance Program Providers
Re: Provider Quality Assurance Participation
The Illinois Department of Healthcare and Family Services (HFS) is committed to ensuring the highest standards of care at a competitive cost for Medicaid beneficiaries. This commitment mirrors the health care system’s transition to measurable outcomes that can be compared across states and populations. As a state, Illinois’ quality outcomes are monitored nationally by the Centers for Medicare and Medicaid Services (CMS), National Centers for Quality Assurance (NCQA) and Agency for Healthcare Research and Quality (AHRQ).
The Healthcare Effectiveness Data and Information Set (HEDIS®) measures are designed to evaluate the effectiveness of a provider’s ability to demonstrate an improvement in its preventive care and quality of care to its members.
Providers are essential to the quality of care process by ensuring that Medicaid-enrolled Illinoisans receive needed care, documenting those services within the medical record and submitting the appropriate coding when submitting a claim for those services. Annually, Illinois Medicaid managed care organizations (MCOs) request medical records from providers as documentation that members received their recommended services if the recommended services cannot be identified through provider claim coding. This request is required to accurately report HEDIS® performance measures.
HFS asks for provider cooperation with the MCOs' medical record requests. Generally, MCO access to medical records is included in the network contracts with their providers. If providers use a medical record vendor, HFS recommends reviewing the contract with the medical record vendor to ensure its process is adequate to protect your network compliance. The requesting MCO will provide instructions and contact information for submitting medical records in response to its request.
Reducing the Number of Medical Record Requests
The biggest opportunity providers have to reduce the number of medical records requests received is to utilize all applicable, appropriate codes when evaluating and billing for patients throughout the year. The HFS fee schedules on the Medicaid Reimbursement webpage contain covered procedures that document compliance with HEDIS® measures.
HIPAA and HEDIS®
Complying with HEDIS® measures is an important 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® purposes. For more information, please visit https://www.hhs.gov.
Increasingly, healthcare payers are tying reimbursement to performance on quality measures, including HEDIS®. HEDIS® performance measures can have a big impact on patients, the perception of the care provided and revenue. Please take every opportunity now to get ahead on HEDIS® improvement.
Questions regarding this notice may be directed to the Bureau of Quality Management at