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Blue Advantage® Medical Risk Reviews

Every year, Blue Cross and Blue Shield of Alabama works to ensure that there is appropriate documentation for our Blue Advantage® members necessary to clarify specific medical conditions. Provider assistance with this effort is very much appreciated as we work to meet the Centers for Medicare & Medicaid Services' (CMS) requirements and standards. This process includes reviewing selected medical records to ensure that our records properly reflect the clinical conditions of our members. This is not an audit, but it is a review of medical records to validate member clinical conditions information we submit to CMS.

We have partnered with Outcomes Health Information Solutions, an Altegra Health company, to conduct these reviews. Outcomes Health is in contract with Blue Cross and Blue Shield of Alabama as a business associate covered by the Health Insurance Portability and Accountability Act (HIPAA). Altegra Health is ethically and legally bound to protect the confidentiality of any protected health information it gathers from clinical medical records provided by any of our physicians, hospitals or medical practices.

A letter will be sent to certain offices to provide advance notice of the Outcomes Health review. A member of the Outcomes Health staff will then contact those offices to discuss the next steps of the process that could include scheduling an on-site review of certain Blue Advantage members' medical records. The Outcomes Health staff member will let you know that he/she is with Outcomes Health, an Altegra Health company. If contacted, please cooperate with Outcomes Health by providing the requested records.

If you have questions, please contact Outcomes Health at 1-855-767-2650 (toll free), or you may contact your Blue Cross Provider Network Services Representative at 1-866-904-4130.

Outcomes Health is an independent company that provides business, technology and
consulting solutions.

Blue Advantage is a Medicare-approved PPO Plan.

Last Updated July 2014