HEDIS® Tip Sheet Lookup
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HEDIS Measures
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 are monitored, and the data is used to evaluate quality of care for members.
- Measures track the actual care received, not just what was ordered.
Data Sources
Administrative Data
Claims (professional, institutional, and pharmacy) and enrollment data used to identify eligible members for measures and the numerator.
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Hybrid Data
A combination of administrative data medical record data.
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Supplemental Data
Additional clinical information about a member, beyond administrative claims, received by a health plan.
- BCBSND is working on the ability to collect supplemental data in 2024.
HEDIS Domains
HEDIS measures fall into one of six domains of care:
Effectiveness of Care
Prevention Screening, Respiratory Conditions, Cardiovascular Conditions, Behavioral Health, Diabetes, Overuse/Appropriateness measures
Access/Availability of Care
Examples include:
- Adults’ Access to Preventive/Ambulatory Health Service (AAP)
- Initiation and Engagement of Substance Use Disorder Treatment (IET)
- Prenatal and Postpartum Care (PPC)
Utilization and Risk Adjusted Utilization
Examples include:
- Acute Hospital Utilization
- Emergency Department Utilization
- Plan All-Cause Readmissions
- Well-Child Visits
Health Plan Descriptive Information
- E.g., Race/Ethnicity, Language Diversity
Measures Reported Using Electronic Clinical Data Systems (ECDS)
- Measures using structured electronic clinical data to document quality patient care.
- Measures are gradually transitioning to ECDS reporting.
Experience of Care
- Measures collected using the survey methodology.
Glossary of Terms
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.
Defining the Primary Care Provider (PCP)
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:
- Family Medicine
- Geriatric Medicine
- Internal Medicine
- OB/GYN
- Pediatric Medicine
Notes regarding PCPs:
- Licensed practical nurses and registered nurses are not considered PCPs.
- Federally Qualified Health Centers are considered PCPs; however, must meet criteria and be reviewed and approved by a certified HEDIS auditor.
Defining the Mental Health Provider
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 bluealliance@bcbsnd.com 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:
- Psychiatrist or Child Psychiatrist
- Psychologist
- Certified Clinical Social Worker or Licensed Master Social Worker
- Registered Nurse (requires certification or master’s degree with psychiatric/mental health)
- Individual practicing as a marital and family therapist.
- Individual practicing as a professional counselor.
- Physician’s assistant certified by the National Commission on Certification of Physician Assistances to practice psychiatry.
- Certified Community Mental Health Center or a Certified Community Behavioral Health Clinic.
Ways to Improve HEDIS Scores
- Maintain accurate clinical documentation.
- Document which patient services are completed.
- Improve provider-patient engagements.
- Focus on preventative screenings.
- Ensure claims are coded correctly.
- Know before the patient arrives what their care gaps may be so they can be addressed during the visit.
- Provide clear discharge instructions and schedule the next appointment before the patient leaves to decrease non-compliance.
Measure and Coding Disclaimer
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.
Questions
Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.
