Do Consumer Assessment of Health Plans and Systems (CAHPS) and/or Healthcare Effectiveness and Data Information Set (HEDIS) ratings affect claims reimbursement?

No, CAHPS and HEDIS do not currently affect reimbursement. These could, however, become the standards for future quality-based reimbursements.

Does HEDIS count toward durable medical equipment (DME) supplies?

HEDIS measures do not apply toward DME supplies.

Is HEDIS required for all specialties (e.g., fertility)?

HEDIS is not a requirement for specialty practices. Specialty practices, however, can gain National Committee for Quality Assurance (NCQA) recognition for successfully coordinating patient care with their primary care colleagues. HEDIS does not measure infertility services.

Why does BlueCross BlueShield of South Carolina share Gaps In Care (GIC) reports with providers?

A care gap occurs when a member has not received a preventive health service. We collect and share this data with our providers to have you reach out to those GIC patients to receive those missed and/or undocumented preventive health services. Closing these gaps also helps to meet HEDIS requirements while improving the overall health of your patients, our members.

Can a practice include more than four diagnoses codes when submitting claims electronically?

Yes, for claims filed electronically we are able to accept up to 12 diagnosis codes for professional claims and up to 25 diagnosis codes for institutional claims. You should contact your clearinghouse if you are experiencing trouble transmitting more than four diagnosis codes. 

Are specialists expected to report all diagnosis codes for HEDIS?

No, we do not expect specialists to report all diagnosis codes for HEDIS. Our efforts to close patient care gaps concentrates on claims data from primary care physicians.

How can I receive a GIC Provider Report?

Please contact the Quality Navigator program at Navigator@bcbssc.com.