Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Comprehensive Diabetes Care

In this blog post we will explore the Comprehensive Diabetes Care HEDIS measure. .

What is New for 2020?

New measure Kidney Health Evaluation for Patient with Diabetes measure was added in 2020. This is a new measure. It evaluates the percent of members that are between 18 and 85 years of age that have diabetes and who received a kidney health evaluation, including estimated glomerular filtration gate test (eGFR) and a urine albumin-creating ration.

What is Comprehensive Diabetes Care Measure?

Measure that evaluates percentage of adult members between ages of 18 and 75 years of age (looks at both type 1 and type 2 diabetes) and who had each of the following:

  1. HbA1c testing
  2. HbA1c poor control (>9%)
  3. HbA1c control of (<8%)
  4. Retinal Eye Exam performed
  5. Blood Pressure Control (<140/90 mm/Hg)\


Record your efforts: document results of, all of the above mentioned test, in the patient’s medical record.

How to meet this measure?

  • Provide reminders to patients for upcoming appointments and screenings.
  • Draw labs in your office if available or refer patients to a local lab for screenings.
  • Refer patients to participating eye professionals for annual retinal eye exams.
  • Follow up on lab test, eye exams and specialist referrals and document in your chart.
  • Telephone visits, e-visits and virtual check-ins are acceptable settings for blood pressure readings and should be recorded in the chart.
  • Include Category II reporting codes on claims to reduce the burden of HEDIS medical record review.
  • Educate patients on topics (for example, home monitoring of blood sugar and blood pressure, taking medications as prescribed, and other healthy lifestyle education like diet, exercise, and smoking cessation).

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Posted in BCBS (Various States), Training, Updates

Anthem BCBS (CT)- Advance Patient Notice and Non-participating providers, 04/01/21

Starting on 04/01/21 and thereafter the participating provider must provide advance notification to the member so the member may choose whether to oppose or approve the use of a non-participating provider for the service or procedure.

Below are several examples that would apply to this policy: (source : Anthem BCBS Administrative policy: Use of a Non-Participating Provider Advance Patient Notice Policy)

  1. A participating physician draws a member’s blood in his or her office but sends the sample to a nonparticipating laboratory for processing.
  2. A participating surgeon involves a non-participating assistant surgeon in a member’s surgery.
  3. A member is referred to a non-participating facility such as an ambulatory surgical center, endoscopy suite or office based surgical suite. (Often a member mistakenly believes that the centers or suite is participating in Anthem’s network because: i) his/her participating physician recommended/referred toit; ii) his/her participating physician or the physician’s partner is the individual performing the procedure or surgery at the facility; or iii) the surgical suite appears to be an extension of the participating physician’s office.)
  4. Durable Medical Equipment (“DME”) order placements are facilitated by a participating physician’s office and the office arranges with, or gives the member instructions to contact, a specific DME provider that is non-participating.

The notice must be provided, completed, and dated by the member, and retained in the member’s medical file a minimum of seven (7) days in advance of the procedure or service.

In addition, providers or facilities who are instructed to provide copies of signed advance notice policies as the result of an audit will now be required to respond with the required information within fifteen (15) days.

This policy will continue to apply to both facilities and professional providers.

Source: Anthem BCBS (CT) provider communications.

To read the full Administrative policy, please click here on the link.

Posted in Insurance, Updates

Empire BCBS (Anthem) (NY, CT, CA, etc)-IngenioRx pharmacy network for 2021

Effective 01/01/2021 IngenioRx will make a new standard pharmacy network available to Empire BCBS (Anthem) patients in 14 states (NY, CT, CA, CO, GA, IN, Kentucky, Main, Missouri, New Hampshire, Nevada, Ohio, Virginia, Wisconsin)

This standard network will include 58,000 pharmacies, including some of already well-known nationwide chains like Costco, CVS, Kroger, Sam’s club, Target and Walmart.

What you need to know:

  1. If currently your Empire BCBS (Anthem) patients do not use the pharmacy in this standard network, they will need to transfer their active RXs to the network pharmacy. This will ensure that there are no interruptions of their coverage.
  2. Empire BCBS (Anthem) will send a notification to the patients, informing them of this change
  3. There will be also a message in the EMR of your patients, that will notify you if the pharmacy the patient is using is in the standard network or not.

If your patients need to search the pharmacy standard network prior to the effective date, they can log into the and find the helpful link to Empire BCBS online pharmacy search tool. Patients can enter address/city/state or zip code to begin search.

If you have any more questions, please click here for FAQs attachment.