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UR HEALTH manages the process of determining participation privilege status in the health plan. We do this by obtaining and reviewing documentation provided by the
applicant or obtained during the process, which may include the applicant’s education,
clinical privileges, accreditation, certifications, professional liability insurance, malpractice history and professional competence.
To become credentialed for the rst time, you will provide:
The Healthcare Efectiveness Data and Information Set (HEDIS®)
Used by 90% of health plans in the U.S.
It ensures health plans are offering quality preventive care and services to members,
and consists of a set of performance measures used by more than 90 percent of U.S.
health plans.
Is mandatory
HEDIS ® annual reporting is mandated by all regulatory agencies. As such, it is extremely
important that providers and their staff members become familiar with HEDIS® to
understand what health plans are required to report.
How does it work?
To ensure the validity of HEDIS results, all data are rigorously audited by certified NCQA
approved auditors using a process developed by NCQA, which has expanded the size
and scope of HEDIS to include measures for physicians, PPOs and other organizations.
Data is collected via HEDIS Data Submission (HOQ and IDSS) System.
HEDIS® data collection begins with claims/encounter data. If the encounter data does
not include evidence of the required performance measures during the specified time
period, the plan clinical staff must review the member’s medical record to determine if
care was provided. Claims/encounter data are the most efficient method to report
HEDIS® measures, which help ensure medical chart reviews and reviewer visits to
providers, are kept to a minimum.
Code accuracy determines proper payment
It is of the upmost importance that providers submit accurately coded
claims/encounters data for each service provided. In order to guarantee that we collect
properly coded administrative data, we have developed a tool to assist our providers
correctly code services rendered.
HEDIS® is a registered trademark of the National committee for Quality Assurance
(NCQA).
Anticipation: key to patient’s care and safety.
We organize and coordinate all patient care activities and share the information between all of the parties involved with a patient’s care, to ensure effective and safe care. We make sure that a patient’s requirements are known ahead of time to the corresponding
people.
The UR HEALTH approach:
Why measuring and reporting on health care quality?
It gives consumers and employers the basis to make informed choices and pursue the
best available care. It also gives feedback to health plans, medical groups and doctors
that they can use to improve quality issues.
How is it done?
Surveys (on-and off-site), audits, satisfaction surveys, and clinical performance
measurement, and more. We use these approaches in a range of accreditation,
certification, recognition and performance measurement plans for different types of
organizations, medical groups and even individual physicians.
How do we ensure compliance?
Through these strategies, we are able to gather the quality information we make
available to consumers, employers, health plans and doctors, and:
• Ensure compliance with applicable regulations related to coding and
documentation guidelines for Risk Adjustment (Federal, State, and County laws).
• Review medical records, patient medical history and physical exams, physician
orders, progress notes, consultations reports, diagnostic reports, operative and
pathology reports, and discharge summaries in orders to verify whether:
– The diagnosis codes are supported by the documentation and ensure with ICD –
10 – CM Guidelines for Coding and Reporting.
– The diagnosis codes for each chronic or major medical condition have been
captured and submitted within the permitted timeframe.
Any diagnosis code is unsubstantiated by the record and should be eliminated.
Review for clinical indicators and query providers to capture the severity of illness of the
patient.
How do we ensure reimbursement?
UR HEALTH ensures consistent physician and facility reimbursement by automatically
evaluating provider claims in accordance with accepted industry coding standards
thanks to a comprehensive national recognized code auditing system to ensure
consistent physician and facility reimbursement. We constantly enhance and update
our code-editing technology to better enforce existing payment guidelines.
Claims will be reviewed to:
Reinforce compliance with standard code edits and rules.
– Ensure correct coding and billing practices are being followed.
– Determine the appropriate relationship between thousands of medical, surgical,
radiology, laboratory, pathology and anesthesia codes.
– Ensure compliance with industry standards.
Correct coding guidelines are established by:
– The Centers for Medicare and Medicaid Services (CMS).
– The American Medical Association (AMA) CPT Coding Guidelines.
– National and Local Coverage Determinations (NCD/LCDs).
– National specialty and academy guidelines.
Our comprehensive pharmacy management service includes: