Healthcare Effectiveness Data and Information Set
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a nationally recognized tool used to measure performance in medical care and preventive health services. It is developed and administered annually by the National Committee for Quality Assurance (NCQA) and is used by the Centers for Medicare & Medicaid Services (CMS) to monitor health plan performance. HEDIS evaluates adherence to both physical and behavioral health clinical practice guidelines.
HEDIS provides a standardized way to assess the quality of care delivered to our members. Employers, consumers, and consultants use HEDIS results to compare health plans consistently and fairly. We use these measures to recognize areas of excellence, identify opportunities for improvement, and develop targeted quality initiatives and educational programs for both providers and members.
NCQA focuses HEDIS measures on conditions and services that affect a large portion of the population. Data is collected year-round through retrospective review of claims and medical records. Submitting claims with complete and accurate coding helps reduce the need for medical record requests.
We understand that provider demands continue to grow in complexity, while delivering high-quality care remains the top priority. As your partner, we are committed to supporting you in improving HEDIS outcomes. Our goal is to help you continue delivering exceptional care while accurately reflecting your performance.
By focusing on key aspects of care and service delivery, HEDIS supports more efficient, comprehensive care and improved health outcomes. Improving HEDIS scores benefits everyone. To support this effort, we provide measure-specific details, highlight important administrative steps, and connect you to helpful resources.
Your participation and compliance with HEDIS help demonstrate the strength and quality of our provider network to employers and consumers.
Medical Records Requests
You may receive requests from us or our business partners to review medical records for one or more of your patients. We appreciate your cooperation as we work together to meet quality goals and improve the overall health of our members—your patients.
We recognize that preparing records for review can be time-consuming. Your commitment to patient care and quality improvement is valued, and we thank you for your support in responding to these requests.
Please also work with your vendors to ensure they comply with medical record requests submitted on your behalf. As a participating provider, your contract requires that BlueCross BlueShield of South Carolina, BlueChoice® HealthPlan of South Carolina, or their authorized partners be allowed to inspect, review, and obtain copies of records at no cost and without delay.
If there’s anything we can do to make this process easier, please let us know. We are happy to meet your needs and can even collect records directly from your office if requested.
For questions or assistance, feel free to contact us at NAVIGATOR@bcbssc.com.
BlueChoice HealthPlan is an independent licensee of the Blue Cross Blue Shield Association.