Quality resources
Like you, we want to ensure our members, your patients, have access to quality care. Our Quality Improvement program uses claims data, medical records, member surveys, supplemental data and other tools to measure quality across all aspects of care, including effectiveness, access, availability and utilization.
This data helps identify opportunities for care, such as preventive screenings our members may need. It also can reflect our members’ experiences with your practice and their health plan.
You play a key role in members’ health care experiences. Read below about quality improvement metrics and resources to support your practice and patients.
Star ratings
The Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System helps our members make informed choices and support quality care.
Many measures that contribute to Star ratings assess patients’ interaction with providers. These include timely access to care, care coordination, preventive care and early detection of disease.
Resource for you: Refer to our Stars Guidebook for more details. You can access it in the Availity® Essentials HealthSpring Medicare Advantage payer space in the resources section.
Member health care experience surveys
Every year, CMS surveys a sample of our members through the Consumer Assessment of Healthcare Providers and Systems Survey and Health Outcomes Survey.
The surveys collect information about members’ experiences with their providers and health plans. Results contribute to Star ratings and identify opportunities to improve member satisfaction.
If you get questions from members who receive a survey, please encourage them to respond. Refer to our Stars Guidebook in Availity Essentials for suggestions on how your practice can impact survey results.
Quality measures
We track Healthcare Effectiveness Data and Information Set (HEDIS®) and pharmacy measures to ensure our members receive effective care.
HEDIS
HEDIS is a standardized set of performance metrics from the National Committee for Quality Assurance. HEDIS results are based on claims, supplemental data, medical records and laboratory data. Health plans report the results to NCQA. Measures we track include:
Breast Cancer Screening
Care for Older Adults
- Functional Status Assessment
- Medication ReviewColorectal Cancer Screening
Controlling High Blood Pressure
Diabetes measures, including glycemic status assessment, eye exams and kidney health assessment
Follow-up After Emergency Department Visits for People with Multiple High-Risk Chronic Conditions
Plan All-Cause Readmissions
Osteoporosis Management
Statin Therapy for Patients with Cardiovascular Disease
Transition of Care
- Notification of Inpatient Admission
- Receipt of Discharge Information
- Patient Engagement After Inpatient Discharge
- Medication Reconciliation Post-Discharge
See our Stars Guidebook in Availity Essentials for more details.
Pharmacy
CMS adopted measures from the Pharmacy Quality Alliance that contribute to Star ratings. They include measures on adherence, statin use and concurrent use of opioids and benzodiazepines.
Resource for you: Refer to our Prescription Drug Coverage Partnership Guide for more details.
The above material is for informational/educational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material, is not a guarantee that the service or treatment is a covered benefit and members should refer to their evidence of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
CPT copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
HEDIS is a registered trademark of NCQA.