DHCS audit in February + NCQA changes to well-child visits

2025 DHCS encounter data validation audit

Starting Feb. 1, 2025, the Health Services Advisory Group (HSAG) will be conducting its annual Department of Health Care Services (DHCS) encounter data (claims) audit.

The audit study period is Jan. 1 through Dec. 31, 2023. During the audit, HSAG will look for encounter data completeness and accuracy through medical record review.

Please watch for faxes from the Alliance, as we will begin contacting provider offices to request medical records at the beginning of February.

What medical records do providers need to submit?

• HSAG will randomly select one date of service (DOS) in the study period. Providers will need to submit the medical record for that DOS.

• Providers will be required to select a second DOS closest to the sample DOS, with the same rendering provider when possible and submit that medical record.

Best practices

• Return medical records within 5 to 7 business days of the request.

• For paper charts, use a provider signature stamp next to handwritten provider signatures.  This allows HSAG to match the provider’s signature to the provider who submitted the claim.

• Submit medical records for all services that are on the claim.

This audit occurs at the same time as the Healthcare Effectiveness Data Information Set (HEDIS) audit. Provider offices may receive multiple medical record requests from the Alliance. However, the sample population and audit period will be different. We thank you for your time and cooperation!

Questions?

If you have any questions regarding the HSAG encounter data validation audit, please email us at [email protected].

In-person well-care visits now prioritized

The National Committee for Quality Assurance (NCQA) is making mandated changes to all pediatric Well-Child Visit measures. This change reflects a return to pre-pandemic guidelines that prioritize in-person well-care visits.

Starting in 2025, telehealth visits will no longer count towards compliance for:

• Well-Child Visits in the First 30 Months of Life.

• Well-Child Visits for Age 15-30 Months of Life.

• Child and Adolescent Well-Care measures.

This change will impact Alliance performance when reporting audited Medi-Cal Managed Care Accountability Set (MCAS) rates for well-visits to the Department of Healthcare Services (DHCS).

We will provide information and updates on this and any other changes through our CBI communications, the Provider Bulletin, the Digest and meetings.

For any questions, reach out to your provider relations representative, or to the CBI team at [email protected].