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HEDIS® Tip Sheet

Emergency Department Visits per 1000

Measure Description

The number of emergency department visits that occur within the attributed members, measured on a per 1,000-member basis and adjusted by risk score.

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Notes

  • The risk adjusted rate is reported as an observed count of ED visits per 1,000 health plan members.
    • It looks at the number of emergency department visits among members attributed to a provider or group.
    • The rate is reported as ED visits per 1,000 members, which makes it easier to compare groups of different sizes.
    • The result is risk adjusted, meaning the measure considers how medically complex the population is.
    • Groups with more complex members may have higher risk scores, which are based on health conditions, demographics, and utilization patterns using the Johns Hopkins ACG® methodology.
  • Denominator: sum of medical member months for the performance period.
  • What a lower rate generally means:
    • Members may be getting care in more appropriate settings, such as:
      • Primary care
      • Same-day appointments
      • Urgent care
      • Telehealth
      • Nurse lines
    • Chronic conditions may be better managed.
    • Patients may have better access to routine and preventive care.
  • What a higher rate may suggest:
    • Members may be using the ED for care that could potentially be handled in another setting.
    • There may be gaps in access to primary care, care coordination, after-hours support, or chronic condition management.
    • Some members may need additional outreach or education on when and where to seek care.
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Exclusions

  • Members enrolled for less than seven (7) months in Medicaid Expansion.
  • Members who are not actively enrolled in Medicaid Expansion at the end of the performance period.
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Best Practices

  • Encourage patients to establish and maintain a relationship with their primary care provider for annual wellness visits, preventive screenings, and care coordination.
  • Proactively engage patients with chronic conditions to help prevent exacerbations, reduce complications, and support ongoing disease management.
  • Educate patients on when to use the ED and when other care options may be appropriate, such as same-day appointments, urgent care, nurse lines, and telehealth.
  • Consider offering extended clinic hours, expanded telehealth access, and nurse line support to improve timely access to care.
  • Conduct scheduled outreach to patients with frequent ED utilization to identify needs, address barriers, and connect them to appropriate care.
  • Use front-desk triage processes to help direct patients to urgent care or other appropriate care settings when clinically appropriate.
  • Reserve same-day appointment availability to support timely access and help reduce avoidable ED visits.

Coding and Benefits Disclaimer

Providers and organizations must submit accurate and complete data in accordance with all billing, coding, and medical policy requirements. HEDIS guidance does not override official coding standards or guarantee reimbursement, as coverage is subject to applicable medical/coding policy and member-specific benefits.

Questions

Should you have specific coding or other questions related to the measure, please send your questions to BlueAlliance@bcbsnd.com.

NCQA Copyright Notice and Disclaimer
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. Any commercial use and/or internal or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Any use of the materials to identify records or calculate measure results, for example, requires a custom license and may necessitate certification pursuant to NCQA’s Measure Certification Program. Reprinted with permission by NCQA. © [2025] NCQA, all rights reserved.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Updated 8/28/2026