Quality Management

On this page:

• Regulatory Requirements
• Healthcare Effectiveness Data and Information Set (HEDIS®)
  • HEDIS Medical Records Collection
  • Coding Guide for HEDIS-Related Star Measures
  • Assistance With Closing Gaps in Care
• What are Medicare Star Ratings?
  • Star Measures
• Program Goals
• Program Activities
• Risk Management/Quality Concern Reporting
• Outcomes, Evaluations and Member-Based Studies
• Access and Availability
• Member and Provider Satisfaction

Regulatory Requirements

An effective Quality Management (QM) program must comply with the applicable federal and state standards. Compliance requires the collaborative efforts of Trinity Health Plan of Michigan and all network providers. Trinity Health Plan of Michigan must meet all regulatory requirements of the MA program, including required quality improvement projects, Stars and HEDIS, enrollee satisfaction surveys and surveys to assess enrollees’ understanding of their health outcomes.

The requirements Trinity Health Plan of Michigan must comply with regarding quality are published in the Medicare Managed Care Manual, Chapter 5. This chapter describes how Trinity Health Plan of Michigan must operate and perform quality measurement and improvement related to the delivery of health care and enrollee services. The chapter’s purpose is to assist MA organizations in developing quality assurance and performance improvement programs, as well as to provide CMS with a road map for monitoring the MA Plan’s Quality Management program.

The requirements in Chapter 5 include:

• Formal QM program with participation by network providers.
• Chronic Care Improvement Program (CCIP).
• Minimum performance levels in studies.
• Annually reported standard quality-related measures including Healthcare Effectiveness Data & Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcome Survey (HOS).
• Maintenance of a health information system that integrates all data necessary to implement the QM program.
• Identification and correction of significant systemic problems.
• Contract with the independent Quality Improvement Organization (QIO)

Healthcare Effectiveness Data and Information Set (HEDIS^®)

HEDIS is a set of standardized performance measures. The purpose of HEDIS is to provide members with a means to assess the value they receive for their health care dollar and to hold health plans accountable for their performance. As a network provider, you may, at times, be required to assist in medical record data collection.

Currently, there are 91 measures across seven (7) domains of care. These domains are:

1. Effectiveness of care
2. Accessibility/availability of care
3. Experience of care
4. Relative resource use
5. Utilization and risk-adjustment utilization
6. Health plan descriptive information
7. Measures collected using electronic clinical data systems

HEDIS Medical Record Collection

These requests are permissible under new privacy regulations, including HIPAA. Specific authorization is NOT required from our members prior to releasing medical records to us. Section 164.506 indicates the routine form you obtain is sufficient for disclosures to carry out healthcare operations. Section 164.501 defines healthcare operations to include quality assessment and improvement activities.

How to Submit Gaps in Care Medical Records

1. Log in to our provider portal.
2. On the portal home page, select Close Gaps in Care.
3. Enter content in all required fields on the Gaps in Care Medical Records tab.
4. Select the Attachments tab. Add your medical record attachment(s), then select Add.
5. Return to the Gaps in Care Medical Records tab and select Submit.

For more detailed instructions, please review our Gaps in Care Tutorial. 

Trinity Health Plan of Michigan strictly maintains the confidentiality of any records, which are only accessed by authorized people adhering to the following guidelines. Records are:

• Kept in a safe and secure location
• Appropriately destroyed when they are no longer needed for the purpose requested
• Not further disclosed or otherwise distributed

We are not asking for nor do we want any medical record information related to psychotherapy, HIV, substance abuse or developmental disabilities.

Further, your Provider Agreement stipulates that copies of members’ medical records shall be provided to Trinity Health Plan of Michigan, or its respective designees, for quality improvement activities (e.g., HEDIS®).

If you have questions around this request, please contact: StarsAndHedis@mchs.com.

Coding Guide for HEDIS-Related Star Measures

We understand the challenges of working with multiple payers and meeting measurements, guidelines and documentation for Medicare beneficiaries. Trinity Health Plan of Michigan has developed a Coding Guide to provide guidance for providers and their staff on HEDIS-related Star Measures and the needed coding and documentation for those measures.

• The Coding Guide includes information on: 
• Star Ratings and the HEDIS reporting process
• Your role in reporting and documenting care
• Medical Record Requests (MRR)
• Star measure guidance and codes

The HEDIS-Related Star Measures Coding Guide is updated annually. Click the links below to view the most up-to-date edition.

2024/2025 HEDIS-Related Star Measures Coding Guide

Advanced Illness and Frailty Value Set

Assistance with Closing Gaps in Care

Our HEDIS coordinators are available to help your office team address gaps in care with calls to members for annual wellness visits and member education or in-house record collection, coding assistance and much more. For more information or to schedule a visit please email StarsAndHedis@mchs.com.

What are Medicare Star Ratings?

The CMS uses a 5-Star quality rating system to measure how well providers and Medicare Advantage health plans are delivering care to members. Successful collaboration with our providers and quality patient care for our members is very important to us. Ratings range from 1 to 5 stars, with 5 being the highest and 1 being the lowest.

The Star measures are made up of performance measures from HEDIS, CAHPS, HOS (measures comparison of members health plan assessment over 2 years), prescription drug program and CMS administrative data.

Star Ratings include measures applied to the following five (5) broad categories:

1. Outcomes: Measures that reflect improvements in a member’s health.
2. Intermediate outcomes: Measures that reflect actions taken with patients that assist in improving a member’s health status, i .e . controlling blood pressure.
3. Patient experience: Measures that reflect the member’s perspectives of the care they receive.
4. Access measures: Measures that reflect processes and issues that could create barriers to receiving needed care, i .e ., Plan makes timely decisions about appeals.
5. Process measures: Those that capture the health care services provided to members who can assist in maintaining, monitoring or improving their health status.

Star Measures

The menu below provides a detailed breakdown of the HEDIS-related Star Measures. Select a star measure to view:

• Measure definition
• CMS weighting 
• Eligible members
• Cut points to receive a 4-5 star rating in 2023 and 2024

Cut points are established by the Centers for Medicare and Medicaid Services and are updated annually.* For a complete copy of 2024 Stars (CY22) cut points for star ratings 1-5, please refer to the following spreadsheet: 2024 Stars Cut Points.

*CY23 cut points to be released in October 2024.

§ New measure, cut points to be released October 2023.

† Star weight increases to 3 in CY23.

Program Goals

The Trinity Health Plan of Michigan QM program is a comprehensive program designed to comply with regulatory requirements to monitor the quality of care and services provided by the Trinity Health Plan of Michigan delivery system. This includes administrative activities of the Plan and its contracted providers.

The program’s purpose is to pursue opportunities for improving medical care, service and the well-being of our members. The focus is on continuous quality improvement with a constant eye on how care and services can be provided at a higher level of quality. Dedicated Trinity Health Plan of Michigan resources are allocated to conduct ongoing quality assessment of performance toward goals with problem resolution, as necessary.

The QM program focuses on three dimensions of health care delivery:

1. Delivery system structure itself
2. Processes involved in delivering health care
3. Results of care delivery

By continuously monitoring and evaluating these three dimensions of health care delivery, Trinity Health Plan of Michigan constantly strives to provide the highest quality care in the most appropriate setting in the most efficient manner to attain the utmost satisfaction of Trinity Health Plan of Michigan members.

Program Activities

A variety of activities are involved in implementing the Trinity Health Plan of Michigan QM program including, but not limited to, the following:

• Risk management/quality concern reporting.
• Monitoring of member service activities, including complaints, appeals and grievances.
• HEDIS data collection/monitoring.
• Member satisfaction surveys.
• Member-based performance improvement projects/studies.
• Provider-based performance improvement.
• Physician access and availability surveys.
• Review of quality concerns for each physician at the time of recredentialing.
• Required data reporting to CMS, such as hospital acquired conditions and serious reportable adverse events.

Risk Management/Quality Concern Reporting

The goal of Risk Management, a component of the QM program, is to control and minimize possible risks arising in the direct provision of care, as well as risks associated with administration of the Plan. The Risk Management/Quality Concern Reporting Form provides a reporting mechanism for contracted providers to report risk management cases or quality concerns. This reporting mechanism is used to identify cases/incidents with potentially serious, undesirable and/or unexpected occurrences that may include loss of life, limb or function or has the potential to adversely affect Trinity Health Plan of Michigan’s reputation. If there is a risk management or quality concern issue in your office regarding a member, please contact Trinity Health Plan of Michigan’s QM Department at the email listed in the Contact Us section of this manual.

Outcomes, Evaluations and Member-Based Studies

The outcomes of clinical care are measured in the following terms: improved health, illness and death reduction, whether the treatment or therapy improved outcome as planned, whether the medical action positively altered the course of the disease’s natural history and whether clinical actions taken provided positive outcomes. Outcomes evaluation identifies potentially adverse events resulting from quality issues. Adverse outcomes identified in significant number or scope are investigated and member-based studies are conducted to improve measurable outcomes.

Access and Availability

An additional measure of quality is the access to care and availability for our members. Access means that medically necessary care is available in a timely manner and that members are able to schedule appointments and obtain any required referrals, as indicated, based on clinical needs. Availability means that Trinity Health Plan of Michigan has made arrangements for the provision of all covered services to members by the proper types, mix and number of network providers. The standards for measuring the adequacy of access and availability are stipulated in the Trinity Health Plan of Michigan Provider agreement and Trinity Health Plan of Michigan’s Network Practitioner’s Access and Availability Standards.

The access and availability requirements which have been approved by Trinity Health Plan of Michigan’s Quality Management Committee are as follows:

• Telephone coverage service 24 hours a day, seven (7) days a week.
• Member calls returned within 24 hours. This includes attempts made to members by leaving voice mail messages, leaving verbal messages with other relatives, etc.
• Urgent appointments scheduled with the PCP or a network PCP acting on your behalf within three days of the request. Urgent appointments are identified as any convolution of persistent symptoms which are perceived urgent by a prudent layperson or that may endanger members not seen within 48 hours.
• Routine appointments are scheduled by the PCP or a network PCP acting on your behalf within ninety (90) days of request.
• Members with a concern they view as needing medical attention prior to routine appointments, under the assistance of health plan case management, may be requested for access within the 90-day timeframe.
• Covered services are provided in a culturally competent manner to all members including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities.
• Members have timely access to copies of pertinent information from their medical records.
• Compliance with standards is evaluated by reviewing medical records, claims and encounter history, scheduling systems and records, complaints and grievances, and member satisfaction and disenrollment surveys.

Member and Provider Satisfaction

Trinity Health Plan of Michigan monitors members’ perceptions of the quality of care and services received. Member satisfaction is considered an indicator of the success of an organization in providing quality care.

Trinity Health Plan of Michigan assesses member satisfaction using the following sources of information: member complaints and grievances, PCP change requests, and random sampling by CMS through use of standardized disenrollment surveys and member satisfaction surveys. Trinity Health Plan of Michigan may also periodically conduct independent provider and member satisfaction surveys to assess provider access and availability, members’ perception of access to care and services, wait times, referrals, explanations of care, members’ education and members’ participation in the decision-making process to meet their health care goals.

Trinity Health Plan of Michigan also monitors providers’ perceptions of the quality of administrative services provided by Trinity Health Plan of Michigan. Network provider surveys are periodically conducted to evaluate provider satisfaction and identify areas for improvement.