The 2011 Healthcare Effectiveness Data Information Set (HEDIS®) medical records data abstraction process will begin in March.  CMS and the National Committee for Quality Assurance (NCQA) require health plans to collect and submit HEDIS data about specific health services, such as cancer screenings and comprehensive diabetes care, received by plan members. Of the 73,000 Humana members in North Carolina, 62,100 members qualify for HEDIS review.

Based on Humana’s current 2011 projection, it will be abstracting about 1,000 records.  Approximately 350 providers and practices will be contacted. The number of records requested for each practice will depend upon statistically valid samples. According to Humana, the average number of charts per practice has been limited and a very small number of practices are actually impacted.  The sample will be largely for Medicare Advantage members.

During this process, Humana associates may request your assistance in retrieving information from your medical records. Your practice may be asked to mail or fax copies of chart components for offsite reviews or contacted by a Humana representative to schedule a visit to conduct an onsite review.

As a result of health reform, CMS is requiring Humana and other MA payers and physicians to provide continuous documentation of quality healthcare around HEDIS measures and to address gaps in reporting these quality data. These results will eventually determine reimbursement methodologies that will directly affect the delivery of health care to Medicare beneficiaries. 

For more questions about the HEDIS Review process in North Carolina, contact the Humana Quality Manager, Lynn Trujillo at 770-350-2153 or [email protected].

This record review is separate from the Medicare Risk Adjustment (MRA) initiative, which deals with accurate coding of health care conditions for Medicare Advantage members.  For MRA questions, contact Yasmin McLaughlin, MRA Supervisor at 770-350-2287 or [email protected].