Medical Record Review for HEDIS Reporting

QualChoice is compiling data on 2017 clinical outcomes to demonstrate performance on Healthcare Effectiveness Data and Information Set (HEDIS) standards, which are designed to help consumers compare performance across plans.

Complete Provider Resource, a medical record retrieval company, will contact your office by fax and telephone to collect medical records on our behalf.

  • Data collection has begun and will continue through mid-May 2018.
  • Information will be collected from individual medical records randomly selected throughout our network.

Review HEDIS notification letter sent to QualChoice Providers.

For any questions or concerns regarding the HEDIS data collection, please email our Provider Relations Representatives at You can also refer to the HEDIS Overview.

New! AutoAuth® Maternity and DRG Notifications

Maternity and DRG notifications are now available through AutoAuth! Effective May 1, all maternity notifications will be handled via the AutoAuth system.

AutoAuth is our automated, evidence-based pre-authorization system, which makes it easy for providers to request authorizations and supply clinical information. We urge providers to sign in and take advantage of these features. The AutoAuth system and training materials are easily accessed through the My Account provider portal at Your Provider Representative can help with any questions.

Helping PCPs Improve Healthcare

We're making healthcare better by working with providers, other insurance firms, and state and federal groups to help PCPs move from volume-based care to value-based care. QualChoice participates in the Patient Centered Medical Homes (PCMH) and Comprehensive Primary Care Plus (CPC+) programs. And we’re educating our members about these initiatives.

CPC+ News and Updates

Our medical policy Tele-Screening for Diabetic Retinopathy (BI570) went into effect on January 1, 2018. Coverage for this service can help improve metrics for diabetic eye screenings.

Also, new utilization and quality reports were made available on the My Account portal in January. These reports cover gaps-in-care and member-level detail on high cost members.

Important reminders:

  • Clinics must submit Category II CPT codes as eCQMs for these measures:
    • Controlling Blood Pressure
    • HbA1c Poor Control
    • Tobacco Use
  • Care Management Fee payments are made through the normal claims process and are posted on your Remittance Advice.
  • The Provider Specialty Cost Data Report is available in the CPC+ section of My Account at This spreadsheet can be used to direct referrals to the most efficient specialists and includes current data for Efficiency Ratio, Patient Risk and Number of Episodes.

For questions, refer to CPC+ Participating Provider Training or find the answers to FAQs here. You can also email your questions to QualChoice at

Health Tips at

To encourage our members to discuss their health concerns with you, we regularly post helpful information on the blog. During 2018, this includes a monthly post to assist with quitting tobacco. Other recent and timely topics include knowing your blood pressure numbers and avoiding the flu.

Alerts and Reminders

Stay Up-to-Date on Medical Policies

Check your inbox on the first day of each month to find QualChoice New & Amended Medical Policies and Coming Amendments in one of these publications:

  • QualChoice Provider Quick Alert
  • Quality Results quarterly newsletter

Medical Coverage Policies Updates for March 2018

View a specific medical coverage policy.