Closing Gaps in Care for Group Medicare Advantage (PPO) members


Through the Blue Cross and Blue Shield National Coordination of Care program, you may receive medical record requests from us for Blue Cross Group Medicare Advantage (PPO)SM members. These include members with coverage with Blue Cross and Blue Shield of Texas as well as Group MA PPO members enrolled in other BCBS plans who are living in Texas. This data helps us monitor for gaps in our members’ care.

What This Means for Medicare Providers

If we need medical records for Group MA PPO members, you will receive requests only from BCBSTX or a vendor, Advantmed. We may request medical records for:

  • Risk adjustment gaps related to claims submitted to BCBSTX
  • Healthcare Effectiveness Data and Information Set (HEDIS®) measures
  • Centers for Medicare & Medicaid Services Star Ratings

Please respond quickly to requests related to risk adjustment, HEDIS and other government-required activities as your contract requires. You don’t need patient-authorized information releases to fulfill medical records requests and risk adjustment gaps through this program.

Important Reminders

  • Use Availity® Essentials or your preferred vendor to verify members’ eligibility and benefits before every appointment. Eligibility and benefit quotes include membership verification, coverage status, prior authorization requirements, provider’s network status for the patient’s policy and applicable copayment, coinsurance and deductible amounts.
  • Ask to see the member’s ID card and a photo ID to help guard against medical identity theft.
  • Notify members that they may be billed directly when services may not be covered.

Questions? Call the customer service number on the member’s ID card.

Advantmed is an independent company that BCBSTX has authorized to request medical records on its behalf.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.