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HEDIS® Tip Sheet

Emergency Department Visits per 1000

Line of business: BlueAlliance Care+ (Medicaid Expansion) 

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.
  • The Risk Score is calculated on the group’s health characteristics, such as medical conditions, demographics, and healthcare utilization patterns. This score is calculated using the Johns Hopkins Adjusted Clinical Group® (ACG®) methodology, which analyzes clinical and demographic data to predict future healthcare needs and costs.
  • Denominator: sum of medical member months for the performance period.
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Best Practices

  • Encourage patients to engage with their PCP for annual wellness visits, screenings, and care coordination.
  • Engage with patients who are diagnosed with chronic conditions to help prevent and minimize exacerbations and complications.
  • Educate patients about appropriate ED use and other options available such as same-day appointments, urgent care, nurse lines, and telehealth.
  • Consider extended clinic and telehealth hours and addition of a nurse line.
  • Offer/coordinate support services for patients diagnosed with chronic conditions or experiencing exacerbations.
  • Consider a scheduled outreach with patients who frequent the ED.
  • Triage patients at the registration desk and direct to urgent care if appropriate.
  • Keep same-day appointments available.
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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.

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.

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 7/16/2025