Category: Medicare

The Blue Cross and Blue Shield Association (BCBSA) has issued a mandate with the goal of improving health outcomes and care management for Medicare Advantage members living outside of a control/home plan service area. This mandate will require a change in the way we process the following requests for Medicare Advantage out-of-area (OOA) membership:
  • Stars care gap requests
  • HEDIS® requests
  • Risk adjustment requests
  • Medical record requests


This change in process applies to all Blue plans and will go into effect on January 1, 2020.


The current process

The current process for the above-mentioned requests involves the control/home plan sending requests to providers via Inovalon/vendor for medical records and supplemental data to address and/or close an identified or suspected HEDIS measure, care gap or risk adjustment. Providers receive requests and submit the requested information to the home plan. The home plan receives the information and uses this information, medical records and supplemental data to complete and/or close the request.


The new process

The new process is specific for Medicare Advantage OOA (PPO) members only. These members will be split out from all other members.


For Medicare Advantage OOA members whose home plan is Empire BlueCross (Empire), the Stars care gap, risk adjustment, HEDIS and medical record requests will be processed via the new BCBSA Provider Engagement Data Exchange (PEX) platform. Empire as control/home plan will submit these requests to BCBSA via the PEX system. BCBSA will then route the request to the health plan with which the provider is contracted (host plan). The host plan will initiate the provider engagement and gather the requested information (for example, medical records). Providers contracted by the host plan will submit the requested documentation to the plan. The host plan will then submit the documentation via the PEX system to BCBSA. BCBSA will sort the responses and documentation and send to the requesting home plan (member’s home plan).


When Empire is the host plan, Empire will receive requests for Stars care gap, risk adjustment, HEDIS and medical record requests from the member’s home plan via the PEX system. Empire will process the requests, engage providers, and submit requests for medical records and/or supplemental data to the provider. When the provider supplies a response (medical records, supplemental data or additional requests for information), Empire will send the responses/documentation to the control/home plan via the PEX system. BCBSA will route the responses/documentation to the requesting home plan.


Provider role in new process

Each provider has a key role in the new process. In order to improve the overall care and health outcomes for members, the provider must:

  1. Respond to requests for medical records and/or supplemental data in a timely manner.
  2. Request additional information from the provider’s contracted plan, if needed, to complete requests.
  3. Follow the standard HEDIS, Stars care gap, risk adjustment and medical records requests processes as outlined in the current process.


As a control/home plan, Empire is taking steps to ensure that providers have the resources needed to complete this new process with little or no impact to the provider’s current operations. Additional provider education resources will be communicated as they become available.


For additional information, please refer to the service numbers on the back of the Member ID Card.


EBCCRNU-0066-19 October 2019


Featured In:
December 2019 Empire Provider News