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. The information below outlines Star Ratings and the quality measures that contribute to them, such as:
- Member experiences, including timely access to care and care coordination
- Clinical care (HEDIS®) quality measures, including preventive care and early detection of disease
- Pharmacy quality measures, including medication management
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 are directly influenced by patient experiences with providers and the care they receive.
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. See our patient experiences checklist on survey topics members may discuss with you. Our Stars Guidebook in Availity Essentials has suggestions on how your practice can impact survey results.
HEDIS measures
We track Healthcare Effectiveness Data and Information Set (HEDIS®) measures to evaluate the care our members receive and identify opportunities to improve health outcomes. Many of these measures also contribute to Star Ratings.
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 Review
Colorectal 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
Pharmacy measures
CMS adopted measures from the Pharmacy Quality Alliance that contribute to Star ratings. These measures focus on areas such as medication adherence, statin use and concurrent use of opioids and benzodiazepines.
Providers can influence performance on these measures by supporting appropriate medication use, addressing barriers to adherence and discussing medications with patients.
Refer to our Prescription Drug Coverage Partnership Guide for more details.
Resources
Refer to the resources section in our Availity Essentials HealthSpring Medicare Advantage payer space for more information, including:
HEDIS measures quick reference guide
Using Current Procedural Terminology (CPT®) Category II codes
Sharing data to close care gaps
Medicare Part C Stars metrics overview
Osteoporosis management in women who had a fracture
Closing gaps in care for older adults
Exclusion codes for documenting frailty and advanced illness
Compare quality: Medicare.gov has a tool to find and compare different types of providers, including physicians, hospitals and nursing homes. Providers and members can use it to compare quality and cost on selected specialties.
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.