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No. To be eligible the organization must perform the functions addressed in the Standards and Guidelines (e.g., QI, UM, CR, RR, and MEM, if applicable), either directly or through a service agreement. If the organization uses a service agreement, the agreement must specify functions covered and be effective before eligibility can be determined.
All other listed eligibility criteria also must be met.
The current timeline says that the auditor selects the measures for review on May 1 and not before; however, if the auditor reviews the health plans internal timelines, and finds that the plan expects to finish MRR early, it is acceptable that the auditor send the measure list when all chart review is complete and he has received a final count of numerator hits for each hybrid measure. For example, if the plan finishes all chart chases on April 29 and provides the numerator count lists, the auditor can select the measures for validation and start the process early.
Note: If the auditor allows for an earlier MRRV timeline, the plan may have to adjust other deadlines affected by this change.
HEDIS 2013
The HEDIS-based Medicare Star measure results are collected, aggregated and reported at the PO level using the same process as for the commercial P4P program, but they are not part of the commercial P4P program and are not listed in the P4P measure set document. MA results will be publicly reported; health plans may choose to use the results as the basis for performance incentive payments, although no standard P4P program for MA currently exists.
The auditor selects one measure from each measure group that applies to the health plan, and exclusions from the exclusions group. If the plan doesnt report any measures in a particular group, the auditor will use his discretion, based on past performance and current progress, to determine if an additional measure should be selected from a group already used.
HEDIS 2013
MRRV Group F (Exclusions) includes all optional and required exclusions and valid data errors found during medical record review. It does not include records excluded through administrative data or that belong to employees or their dependents. Other hybrid medical record exclusions that should not be reviewed in Group F are exclusions for CBP and the HbA1C Less Than 7% indicator. Because of the large volume, auditors review exclusion rates for these indicators separately. See the instructions in Volume 5, page 65 for reviewing CBP and HbA1c<7%.
HEDIS 2013
If a plan fails the test – one error in each of two samples – and cannot correct the error and resubmit the correction to the auditor, the plan may not use the Hybrid Method for reporting that measure. The plan can report the administrative rate or report an NR for that measure. The auditor must determine whether the error affects all the other measures in the group and their reportability.
HEDIS 2013
Only tests administered by a qualified provider may be used for HEDIS reporting. Self-administered tests (including home-test kits) where the patient performs the test and obtains the result are not eligible for use in HEDIS reporting.
Results from a home test kit where a qualified provider uses the kit to conduct a test or determine the results in the office are eligible for HEDIS reporting. If any home test is billed by a qualified provider using a code specified in the measure, it is eligible for use in HEDIS reporting; the code alone indicates compliance.
HEDIS 2013
Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.
The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.
HEDIS 2013
