Administrative bulletin: 2026-03-003 Quality information

Professional and facility Providers

Medical record collection for quality reporting of HEDIS®

KEY POINT: We are continuing to collect medical records and need your help. Your office or facility may be contacted by a representative from Capital Blue Cross to request medical records. Please be sure to provide the required documentation within five (5) business days of request.

Capital Blue Cross collects medical record data for Healthcare Effectiveness Data and Information Set (HEDIS®) using specifications by the National Committee for Quality Assurance (NCQA). HEDIS is the most widely used and nationally accepted effectiveness of care measurement available. In addition to helping us meet CMS requirements, HEDIS medical record collection plays an important role in supporting the care you provide to your patients. Medical record collection allows visualization of current care status and the ability to engage your patients and increase compliance across the mandated requirements.

Medical record requests are very important. Please note – the records are required from you within five business days of the request. Please work with your medical record vendors to ensure compliance and that records are provided at no cost, per your contract with Capital.

If you have any questions or concerns, please contact your Provider Engagement Consultant or visit the Provider engagement consultant look up tool and enter your NPI or TAX ID to identify your designated point of contact at Capital Blue Cross.

Colorectal Cancer Screening (COL)

KEY POINT: Helpful information is provided about the COL measure, including tips for addressing the measure.

Clinical guidelines recommend regular colorectal cancer screening begin at age 45 for people with average risk and continue through age 75. The American Cancer Society Guideline for Colorectal Cancer Screening¹ recommends that people at average risk of colorectal cancer start regular screening at age 45. Additionally, the COVID-19 pandemic initially resulted in most elective procedures being put on hold, leading to many people not getting screened for cancer.

The HEDIS^® measure for Colorectal Cancer Screening examines rates for persons aged 45 – 75. Screenings may be stool-based tests or a visual (structural) exam of the colon and rectum. The following meet the HEDIS® 2026 criteria for timely colorectal cancer screening:

• Fecal Occult Blood Test (FOBT) during the measurement year.
• FIT-DNA test during the measurement year or two years prior.
• Flexible Sigmoidoscopy during the measurement year or four years prior.
• CT Colonography during the measurement year or four years prior.
• Colonoscopy during the measurement year or nine years prior.

When measuring rates of colorectal cancer screening using HEDIS^® specifications, certain patients are excluded:

• Diagnosis of colorectal cancer.
• Documentation of total colectomy.
• Hospice or palliative care.
• Patient who expired during the measurement year.

Provider groups who utilize Capital's Theon Care Collaborator population health management tool can submit medical record documentation that meets the specifications to validate that the patient received the appropriate services.

Please refer to the Preventive Services Health Coverage Guidelines for more information related to applicable procedure codes and diagnosis codes. The guidelines will be periodically updated to include new coverage guidance and will include the above information with the next update.

Provider groups may direct members to check out helpful news and cancer prevention information on the Capital Blue Cross member page: Capital Journal

Source: ¹2026 American Cancer Society “American Cancer Society Guideline for Colorectal Cancer Screening.”

American Cancer Society

Plan All-Cause Readmission (PCR)

KEY POINT: Helpful information is provided about the PCR measure, including tips for addressing the measure.

Measure importance:

Health risks associated with hospitalization are high and often include infection, adverse drug events, loss of function, isolation, negative quality of life, and even costly readmissions. Managing care transitions is an essential point in managing members’ overall care. Literature supports that, often costly, readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse outcomes for patients¹.

Not all preventable readmissions can be avoided; most potentially preventable readmissions can be prevented if the best quality of care is rendered and clinicians are using current standards of care. Hospital readmissions may indicate poor care or missed opportunities to coordinate care better. Research shows that specific hospital-based initiatives to improve communication with beneficiaries and their caregivers, coordinate care after discharge, and improve the quality of care during the initial admission can avert many readmissions².

The Plan All-Cause Readmission (PCR) HEDIS measure aims to distinguish readmissions from complications of care and pre-existing comorbidities³. This measure assesses the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days for members 18 years of age and older in the following categories:

• Count of Index Hospital Stays.
• Count of 30-Day Readmissions.
• Average Adjusted Probability of Readmission.

Exclusions:

• In hospice or using hospice services anytime during the measurement year.
• Admission date is the same as the discharge date.
• Member died during inpatient stay.
• Acute inpatient hospital admission for a principal diagnosis of pregnancy.
• Principal diagnosis originating in the perinatal period.
• Hospital Stays if the direct transfer's discharge date is after December 1 of the measurement year.

Which services count?

Include all services, whether they are paid or expecting to pay (include denied claims) when applying risk adjustment in the Risk Adjusted Utilization measures. Do not include denied services (only include paid services and services expected to be paid) when identifying all other events (e.g., the IHS in the PCR measure or observed events in the other risk-adjusted utilization measures).

Best practices:

• Establish clinical pathways and standardized EMR order sets to manage and document discharges and follow-up outreach effectively.
• Educate patients on understanding their diagnosis, managing their medications, self-care, learning to understand discharge instructions, diet, and communicating with their healthcare team. Assess patient understanding and provide re-teaching or referrals to condition educators as needed.
• Perform medication reconciliation with the patient/caregiver to verify current medications, adverse side effects affecting the desire to take medications, any changes or additions to the medication regimen, and the patient’s ability to afford prescribed medications and take them as directed.
• Identify and manage barriers to non-compliance: knowledge gaps, health literacy, language, cost, cognition, transportation, financial, etc.
• Contact Capital's Care Management at 888.545.4512 to support transitions in care.
• Use motivational interviewing to help members commit to required visits with their primary care provider and set goals for taking their medications.
• Refer to Capital's Comprehensive Performance Measures Guide for information about CPT codes, exclusions, and documentation requirements. The most recent version of Capital's Comprehensive Performance Measures Guide can be found on Capital's Clinical Quality and Education page. The page provides easy access to various resources, including Capital's HEDIS Measure Exclusion Guide and Theon Guidance, as well as additional materials.

Contact your Provider Engagement or Population Health consultant with any questions.

¹Medicare Payment Advisory Commission. “Data Book: Health Care Spending and the Medicare Program.” Baltimore, MD: MedPAC, 2015. Available at http://medpac.gov/documents/reports/june-2015-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf?sfvrsn=0 (Accessed May 4, 2016)

²Gallagher, B., L. Cen and E.L. Hannan. 2005. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.1636 (Accessed October 13, 2008)

³Gallagher, B., L. Cen and E.L. Hannan. 2005. Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.1636 (Accessed October 13, 2008)