CMS STAR measure & hierarchical chronic condition guidance
CMS Star Measures are national quality benchmarks that publicly reflect the performance of Primary Care Physicians, IPAs, and Health Plans both to your patients and to the Centers for Medicare & Medicaid Services (CMS). Strong STAR Scores mean better prevention and chronic care (fewer complications and hospitalizations), higher patient satisfaction, and preservation of richer plan benefits. They also influence patient choice, network participation, and oversight by CMS.
This page gives clinicians clear steps to complete Star Measures the right way; What counts as compliant, practical at-home/telehealth options, documentation and billing essentials, and how to monitor progress in Cozeva through the Empire Portal.
We summarize per-PCP Quality performance in our weekly emails to registered portal accounts. Metrics such as STAR Measure compliance rate, RAF score, and AWV Completion Rate.
For assistance email us at: Quality@EmpireCare.com
Quality programs & performance resources
Annual wellness visits
Annual Wellness Visits are a prime opportunity to capture Chronic Condition Diagnoses, and close STAR Measure Gaps to then be reported via claim. However, any office visit can be just as useful in closing these gaps. Here are forms relating to the Annual Wellness Visit. Member-Specific Chronic Condition and STAR Measure Gaps are viewable in Cozeva. Simply log into our Portal > Resources > Cozeva. Click Forms Below to Download:
Annual Wellness Exam Form (PDF) ↓
Advanced Care Directive (CPT 99497) (PDF) ↓
Cozeva - simplify gap closure
When encountering a member, we suggest using Cozeva through our Portal to make the visit as productive as possible. By printing the member's CareOps Page (Member Profile Overview), it highlights Past & Suspect Chronic conditions for recapture, and applicable CMS Star Measures for closure. Below are helpful documents for using Cozeva.
Click Forms Below to Download:
Cozeva Practice Guide (PDF) ↓
STAR measure & chronic condition guidance
Below are Critical STAR Measure Reporting Guidance for Diabetic HbA1c and Blood Pressure. Cozeva will sort members into what Measures they qualify for based on their conditions. The documentation below highlights what counts as a compliant result, and the CPTII codes used on a claim to close these gaps.
Further, we have included a "Common HCCs by Disease Group" document which highlights many common Chronic Conditions that map to a RAF-bearing HCC. RAF Scores tell Physicians, Groups, Plans, and CMS, how chronic a member is, allowing for appropriate care and financial management. Click Forms Below to Download:
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STAR Measure - Blood Pressure & Diabetic A1c Quick Reference (PDF) ↓
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STAR Measure - Cozeva Submission of KED, Colorectal Cancer, Diabetic A1c Screening Measures (PDF) ↓
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Blood Pressure - Member Self Reporting via Telehealth - PCP Instructions (PDF) ↓
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Blood Pressure - Member Self Reporting via Telehealth - Member Instructions - English (PDF) ↓
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Blood Pressure - Member Self Reporting via Telehealth - Member Instructions - Spanish (PDF) ↓
Quality bonus programs
At Empire, we wish to empower and reward our PCPs and their Staff for the important work they do in keeping our patients healthy. For this reason, starting 7/1/2025, we have launched new Quarterly PCP & Staff Incentive Programs. Click Forms Below to Download:
Diagnostic testing
Labcorp is our Lab Partner providing Laboratory testing for critical STAR Measures such as:
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Kidney Health Evaluation (KED) - Results for Blood eGFR, Urine Creatinine & Microalbumin
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Diabetic A1c Values (HbA1c)
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Colorectal Cancer Screening (FOBT)
You may report screening results for these STAR measures by claim, or via Cozeva.
See the section above for Cozeva Submission guidance.
You may collect Blood, Urine, and Fecal samples in clinic for LabCorp pickup, optimizing workflow and member experience.
RadNet is our imaging partner, providing screenings for STAR Measures such as:
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Osteoporosis Management in Women Who Had a Fracture (OMW) - DEXA Scan
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Breast Cancer Screening (BCS-E) - Mammogram