HEDIS measures of focus
Our goal at Magellan Complete Care of Virginia (MCC of VA) is to work with our providers to ensure that every member receives the very best care. In addition, state and federal governments are demanding a healthcare industry that is driven by quality.
MCC of VA monitors the following measures:
- Diabetes monitoring for members with diabetes
- Behavioral Health & Medical readmission rates
- Adolescent Well-Care Visits
- Adult access to preventive/ambulatory health services
- Prenatal and Postpartum Care
- Childhood Immunization Status
- COPD or Asthma Admission Rate
- Heart Failure Admission Rate
MCC of VA supports and promotes the use of evidence-based performance measures that help drive the adoption of recommended care and improvements in population health. The Healthcare Effectiveness Data and Information Set (HEDIS®), is owned by the National Committee for Quality Assurance (NCQA) and is the most widely used measure set for driving quality rating systems, as well as for its individual measures which are increasingly used by employers, health plans, and government agencies to drive pay-for-performance quality programs.
HEDIS measures cover a wide span of indicators related to the management of physical and behavioral health. Final performance is calculated over the first six months of every calendar year for the prior calendar year. Some measures allow medical record data, and some reviews occur across a multi-year period.
In areas of most concern to your patients, HEDIS helps compare how managed care plans perform. Magellan Complete Care of Virginia closely monitors the HEDIS rates as a way to help us identify opportunities for us to improve the health of our members.
We depend on our providers to:
- Submit accurate and complete claims and encounter data within a timely manner of the rendered service
- Ensure that you and your office staff comply with our requests for medical records in the timeframes requested
- Notify our staff or delegated vendor immediately if the patient listed on a request for medical records is not seen by your practice
- Provide medical records for a member who was seen by a provider who has retired, died or moved, as data collection can go back as far as 10 years
- Assist us with quality improvement activities that improve the health and wellness of our population
MCC of VA’s responsibility is to:
- Provide education and information as needed regarding HEDIS and other performance measures for which we request your cooperation and assistance
- Communicate with you by phone, fax, in writing, or through secure electronic communications to request medical record documentation to verify service delivery
Magellan Complete Care of Virginia HEDIS 2019 Results for Measurement Year 2018
Examples of measures we have improved upon and/or met our performance goals include:
- Well Child Visits
- Adolescent Well-care Visits
- Controlling Blood Pressure
- Cervical Cancer Screening
- Colorectal Cancer Screening
- Comprehensive Diabetes Care – several sub-measures
- Postpartum Care
Additionally, we are currently involved in four (4) rapid-cycle Performance Improvement Projects (PIPs) in conjunction with DMAS and their EQRO focused on the following:
- Reducing rates of emergency rooms visits within the CCC Plus population
- Improving rates for follow-up after discharge within the CCC Plus population
- Improving rates of compliance with prenatal care within the Medallion 4.0 population
- Improving rates of tobacco cessation in pregnant women within the Medallion 4.0 population
Magellan Complete Care of Virginia (MCC of VA) is proud to announce we received National Committee for Quality Assurance (NCQA) Accreditation for Medicaid HMO and an NCQA Distinction for Long Term Services and Supports.
MCC of VA was accredited for service and clinical quality that meets or exceeds NCQA’s rigorous requirements for consumer protection and quality improvement. Our Long Term Services and Supports program was recognized for delivering efficient, effective person-centered care.
NCQA Accreditation is important because it is considered the gold standard of healthcare quality assessment. It provides organizations with a way to improve and regulate their operations so they can be as effective as possible in providing the best care. It’s the only evaluation program that uses clinical performance (HEDIS® measures) and consumer experience (CAHPS® measures) criteria to generate results.
Provider rights and responsibilities
MCC of VA Network provider participation
MCC of VA is dedicated to selecting healthcare professionals, groups, agencies and facilities to provide member care and treatment across a range of covered services as defined by Virginia Department of Medical Assistance Services (DMAS).
To be a network provider of healthcare services with MCC of VA under the CCC Plus and Medallion 4.0 programs, you must be credentialed and contracted according to MCC of VA and DMAS standards. Providers are subject to applicable licensing requirements. You have the right to request the status of your credentialing or recredentialing application.
Your responsibility, as an MCC of VA network provider of healthcare services, is to:
- Provide medically necessary covered services to members whose care is managed by MCC of VA and comply with all applicable non-discrimination requirements
- Maintain eligibility to participate in Medicare/Medicaid or other federal or state health programs. You may not be excluded from participation while under agreement with MCC of VA
- Comply with all terms of your Participating Agreement. In the event there is a conflict between the terms of your Agreement and the terms of the CCC Plus or Medallion 4.0 contract, the DMAS contract will apply
- Review information submitted to support your credentialing application and correct any errors
- Follow the policies and procedures outlined in the MCC of VA provider handbook, any applicable supplements and your provider participation agreement(s) as well as DMAS policies and regulations
- Provide services in accordance with applicable Commonwealth of Virginia and federal laws and licensing and certification bodies. Contracted providers for the CCC Plus or Medallion 4.0 networks are required to abide by DMAS regulations and manuals, and maintain active licensure for their contracted provider type and specialty at each service location
- Provide covered services to MCC of VA members as outlined in the MCC of VA provider handbook and applicable supplements and your provider agreement(s), as well as DMAS policies and regulations without exclusion or restriction on the basis of religious or moral objections
- Agree to cooperate and participate with all system of care coordination, quality improvement, outcomes measurement, peer review, and appeal and grievance procedures
- Make sure only providers currently credentialed with MCC of VA render services to MCC of VA members
- Follow MCC of VA’s credentialing and re-credentialing policies and procedures
- Participate and collaborate in value-based payment programs and strategies (as agreed upon in your Participating Provider Agreement) that contribute and align with MCC of VA and DMAS care goals and outcomes for members
MCC of VA’s responsibilities are to:
- Assist with your administrative questions during normal business hours, Monday through Friday
- Not prohibit, or otherwise restrict healthcare providers acting within the lawful scope of practice, from advising or advocating on behalf of the member who is the provider’s patient, for the member’s health status, medical care, or treatment options, including any alternative treatments that may be self-administered, any information the member may need in order to decide among all relevant treatment options, the risks, benefits, and consequences of treatment or non-treatment. And not prohibit nor restrict the member’s right to participate in decisions regarding his or her healthcare, including the right to refuse treatment, and to express preferences about future treatment decisions
- Ensure health equity in the coverage and provision of services. This includes parity in process and coverage policy between covered medical and behavioral health service needs
- Ensure members’ access to Native American and/or other Indian Health Services (IHS) providers, where available
- Assist providers in understanding and adhering to our policies and procedures, the payer’s applicable policies and procedures, and other requirements including but not limited to those of the National Committee for Quality Assurance (NCQA)
- Maintain a credentialing and recredentialing process to evaluate and select network providers that does not discriminate based on a member’s benefit plan coverage, race, color, creed, religion, gender, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical disability or other status protected by applicable law