CurrentDelaware First HealthPolicy N/A

Medical Record Collection Process — Coverage Criteria for Record Requests

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Governs Delaware First Health's process for requesting and collecting medical records from providers for HEDIS and other quality measure reporting to CMS and state agencies; applies to providers identified as a member's PCP or who submitted relevant claims/encounters.

Policy Summary

PayerDelaware First Health

PolicyMedical Record Collection Process — Coverage Criteria for Record Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrepare and make requested medical records available to Delaware First Health or its authorized vendors for HEDIS and RAPS chart collection as scheduled (fax, mail, or on-site).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1–Apr 28, 2026collection window

Apr 21, 2026latest requested date

HEDIS / CMSdrivers

Coverage Criteria

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CurrentDelaware First HealthPolicy N/A

Medical Record Collection Process — Coverage Criteria for Record Requests

Customize your policy alerts

Sign up for all Delaware First Health policy alerts

Know when Delaware First Health releases new policies or updates existing guidance.

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Policy Summary

PayerDelaware First Health

PolicyMedical Record Collection Process — Coverage Criteria for Record Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrepare and make requested medical records available to Delaware First Health or its authorized vendors for HEDIS and RAPS chart collection as scheduled (fax, mail, or on-site).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 1–Apr 28, 2026collection window

Apr 21, 2026latest requested date

HEDIS / CMSdrivers

Coverage Criteria

This policy governs Delaware First Health's process for requesting and collecting medical records from providers for HEDIS and related quality reporting to CMS and state agencies. There are no explicit exclusions listed in the policy document. Vendors will only contact your office to collect charts when you are identified as the member's assigned or previous primary care provider (PCP) or when you have submitted a claim or encounter related to a HEDIS measure. Vendors contracted by Delaware First Health may also collect charts as part of their work for other health plans, but collection for a given member is limited to those providers meeting the assignment or claim/encounter criteria.

Provider Actions and Obligations

Prior Authorization

Prior authorization not applicable for record requests

No prior authorization is required for medical record requests made by Delaware First Health or its contracted vendors for HEDIS or Medicare RAPS reviews; vendors will request records directly during the annual collection window.

Note

High-priority provider requirement: make records available for quality review

Delaware First Health requires providers to make medical records available for HEDIS-related review; vendors engaged by the plan will contact offices to schedule record collection between January 1 and April 28, 2026.

Documentation Required

Record preparation and delivery instructions

Vendors will fax a member pull list with instructions once a session is scheduled; providers should prepare records for fax, mail, or on-site pickup and may request vendor assistance in pulling charts or have files ready for the vendor on arrival.

Vendor will fax the member pull list and preparation instructions.
Prepare records for fax, mail, or on-site collection as instructed.
If needed, request vendor assistance to pull charts or have files ready for on-site sessions.

Denial Risk

Obligation to provide medical records to Delaware First Health or authorized vendors

Providers are obligated to comply with requests from Delaware First Health or its authorized vendors—these vendors have signed BAAs and operate under HIPAA; failure to provide requested records may jeopardize quality reporting obligations.

Vendors have signed Business Associate Agreements and are HIPAA-compliant.
Collection must be accommodated at the earliest mutually agreeable date, but no later than April 21, 2026.

Background

Delaware First Health conducts an annual medical record collection to support reporting of clinical quality measures required by CMS and state agencies. One or more authorized vendors will schedule medical record collection between January 1 and April 28, 2026 to obtain charts needed for HEDIS and Medicare RAPS reviews. Because some required data are not available in claims or encounters, chart review and abstraction by authorized vendors is necessary to meet reporting obligations.

Definitions

inv-07: HEDIS — Healthcare Effectiveness Data and Information Set definition

DefinitionHealthcare Effectiveness Data and Information Set (HEDIS) — a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) used for quality reporting to CMS and state agencies.

PurposeUsed to report clinical quality measures that often require information not available in claims or encounters, necessitating medical record requests and chart abstraction.

Vendor involvementDelaware First Health engages medical record collection vendors to collect records required to complete HEDIS reviews; vendors sign Business Associate Agreements and adhere to HIPAA.

Provider obligationAs a Delaware First Health provider, you are required to fulfill HEDIS-related medical record requests made on the plan's behalf.

inv-08: RAPS — Medicare Risk Adjustment Processing System definition

DefinitionMedicare Risk Adjustment Processing System (RAPS) — a review process linked to Medicare risk adjustment used when vendors collect charts for risk adjustment reviews.

Overlap with HEDIS vendorsVendors that collect charts for HEDIS also contract with other health plans to collect charts for Medicare RAPS reviews, which can reduce scheduling burden on provider offices.

Collection windowMedical record collection for HEDIS and RAPS will be scheduled between January 1 and April 28, 2026, with records requested no later than April 21, 2026.

Policy Summary

PayerDelaware First Health

PolicyMedical Record Collection Process — Coverage Criteria for Record Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrepare and make requested medical records available to Delaware First Health or its authorized vendors for HEDIS and RAPS chart collection as scheduled (fax, mail, or on-site).

SourceLink

On This Page

Medical Record Collection Process — Coverage Criteria for Record Requests

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Coverage Criteria

Medical Record Collection Process — Coverage Criteria for Record Requests

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Coverage Criteria

Provider Actions and Obligations

Ordering Requirements for Record Requests

Background

Definitions