Providers: Help Sunshine Health Access Medical Records

Date: 06/28/24

Fort Lauderdale, Florida

Providers who respond to requests for medical records are helping Sunshine Health meet regulatory requirements and better manage costs and rates for our partner providers and our members.

We recognize that health plans frequently approach you seeking records for multiple patients. These requests can tie up your organization’s resources, so we put together this tip sheet to streamline the record retrieval process.

If you have an Electronic Medical Record (EMR) system that we can use to obtain records, please contact your Provider Engagement Administrator so we can gain access. Visit the Find Your Account Manager tool to confirm the individual supporting your specialty and region.

Medical Record Chart Retrieval Tips
Program	Definition	Requirements
HEDIS (Healthcare Effectiveness Data and Information Set) Audit	HEDIS is a performance measurement tool coordinated and administered by the Centers for Medicare & Medicaid Services (CMS) to monitor the performance of managed care organizations. The HEDIS project is a retrospective review of services and performance of care. Results are used to measure performance, identify quality initiatives and educate providers and members.	For CMS/NCQA and HHS Medicaid Ambetter (Marketplace) Wellcare (Medicare) Annual Audit Vendors: Datavant Group (formerly Ciox)
RADV (Risk Adjustment Data Validation) Chart Retrieval	HHS RADV stratifies its sampling among adult, child and infant patients by metal levels (silver, gold, platinum) offered by qualified health plans. A random sample of 200 patients with a variety of risk scores and Hierarchical Condition Categories (HCCs) is chosen to prove the validity of the HCC value that was paid to the health plan by CMS for the reported ICD-10 code.	For CMS/HHS Ambetter (Marketplace) Wellcare (Medicare) Annual Audit Internal Record Retrievals Vendors: Optum Health Datavant Group (formerly Ciox)
Risk Adjustment “Suspecting”	“Suspecting” is the process of identifying additional health conditions via reviewing medical records. Medical records are chosen based on member/patient demographics and other claims activities. Records are reviewed and coded for additional health conditions that fall into an HCC category.	Ambetter (Marketplace) Wellcare (Medicare) 1-2 Times a Year Internal Record Retrievals Vendors: Datavant Group (formerly Ciox) Datafied, Inc.

Calendar
	Jan		Feb	March	April	May	June	July	Aug	Sept	Oct	Nov	Dec
HEDIS		Hybrid Chart Retrieval					Year-Round Gap Closure
RADV		Wellcare RADV Retrieval				Ambetter RADV Retrieval
Risk Adjustment Suspecting	Previous Year’s Ambetter Chart Retrieval					Wellcare Chart Retrieval				Current Year’s Ambetter Chart Retrieval

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