FAQ Directory: HEDIS

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.  

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS MY 2023

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

• 2106-3 = “White” (CDC Race and Ethnicity).
• 2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS MY 2024

It depends:

• For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required. 
• For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS MY 2024

Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR:    Step 2 of the event/diagnosis (Asthma Value Set)
GSD:    Numerators (HbA1c Test Result or Finding Value Set)
EED:     Event/diagnosis (Diabetes Value Set)
OMW:   Step 2 of the event/diagnosis (Fractures Value Set)
SSD:     Numerator (HbA1c Test Result or Finding Value Set)
SMD:    Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC:    Numerator (LDL-C Test Result or Finding Value Set)
IET:      Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E:  Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)

HEDIS MY 2024

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS MY 2024

Yes. Race and ethnicity stratification is not required for traditional reporting of CIS and CCS. The race and ethnicity stratifications are reported when using the Electronic Clinical Data Systems reporting standard for CIS-E and CCS-E.

HEDIS MY 2024

Although HEDIS digital measure logic references “Explanation of Benefit (EOB),” this is not referenced as a data source in HEDIS Volume 2. In FHIR, the EOB resource represents claims that have been adjudicated, and includes data elements from both Claim and ClaimResponse. The digital logic was written to include the Claim/ClaimResponse resource for claims that are still processing; the ExplanationOfBenefit resource is for claims that are adjudicated.

HEDIS MY 2024

No. The correct time frame for identifying palliative care is “at any time during the 365 days prior to the IPSD through 61 days after the IPSD.” This correction will be in the MY 2024 Technical Update.

HEDIS MY 2024

The age stratifications listed under “Characteristics” are incorrect; they should be 46-50 and 51-75. This correction will be in the MY 2024 Technical Update. The age stratifications listed in the Data Elements for Reporting tables are correct.
 

HEDIS MY 2024

Yes. If medical records document that the member meets exclusion criteria, the member is excluded from the sample and replaced with a member of the oversample.
 

HEDIS MY 2023

The KED measure provides actionable information for chronic kidney disease identification and management. General guidance from our experts is that tests included in the measure should align with guideline recommendations from the American Diabetes Association and the National Kidney Foundation. For this reason, only quantitative uACR tests are allowed and semi-quantitative tests are not considered measure compliant. Removing LOINC code 32294-1 from the value set maintains these coding parameters.

HEDIS MY 2024

Organizations cannot use PCS responses that are over 3 years old. If your question relates directly to a measure specification or general guideline that was revised from a previous measurement year, submit the question rather than using the answer in PCS.

HEDIS MY 2024