Search and browse available HEDIS® Tip Sheets
Healthcare Effectiveness Data and Information Set (HEDIS) is a National Committee for Quality Assurance (NCQA) tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service.
HEDIS measures fall into one of six domains of care:
Measurement Year: For most measures, the measurement year is the 12-month timeframe during which a service was rendered, generally January 1 – December 31.
- Please contact BlueAlliance@bcbsnd.com if you have questions about a measure’s timeframe.
Denominator: The number of members who qualify for the measure criteria, based on the HEDIS technical specifications.
Numerator: The number of members who meet compliance criteria based on the HEDIS technical specifications.
Required Exclusions: Members are excluded from a measure denominator based on a diagnosis and/or procedure captured in their claim/encounter/pharmacy data.
- There may be exclusions specific to a measure while other exclusions are more universal.
A PCP is a physician or nonphysician (e.g., nurse practitioner, physician assistance, certified nurse midwife) who offers primary care services. Provider types that are identified as a PCP include:
Notes regarding PCPs:
A mental health provider is a provider who delivers mental health services. For each provider type listed below, there are various certifications, experience, and criteria required. In addition, the provider types below need to meet any state practice requirements. Please contact firstname.lastname@example.org if there are questions related to a specific mental health provider or provider type.
Provider types that may be considered a mental health provider include:
The analysis of any medical coding question related to a measure is dependent on the measure’s technical specifications including the factual situations present related to the member, the practice, the professionals, and the medical services provided.
HEDIS measures can have different scenarios and numerous codes (CPT®, HCPCS, ICD-10, Place of Service, etc.) that help determine the denominator and the numerator. Not all HEDIS Tip sheets contain codes due to the number of codes and combination of codes that may apply.
Codes have been added to some of the HEDIS Tip sheets and are a guide. The codes that have been added may not include all available codes.
Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.