FAQ Directory: HEDIS

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1.15.2021 General Guideline 15 When a member has dual enrollment in Medicaid/Medicare how long must the member be enrolled in Medicare (PFFS or primary Medicare enrollment in another organization) to be removed from the Medicaid product line?

There is no minimum enrollment requirement. Per General Guideline 15, members must meet the measure’s continuous enrollment requirements and be considered dually enrolled based on continuous enrollment criteria or the service date.
Organizations must follow General Guideline 15 with regard to assessing coverage and should review enough data to meet the measure specification requirement.

HEDIS MY 2021

1.15.2021 General Guideline 15 What is the time frame for assessing dual enrollment?

As stated in the General Guideline 15, the time frame is assessed by measure. For measures with continuous enrollment, dual enrollment is determined as of the end of the continuous enrollment period, or the last enrollment segment, if there is a gap at the end of the continuous enrollment period.
For measures without a continuous enrollment requirement, members must have dual enrollment on the date of service or the date of discharge.

HEDIS MY 2021

1.15.2021 General Guideline 15 What type of Medicare enrollment counts when assessing members with dual Medicaid and Medicare enrollment?

General Guideline 15 includes language about Medicare contracts required to report HEDIS. These are meant to indicate Medicare Part C or Medicare Parts A and B. Having only Medicare Part D does not qualify as coverage for dual enrollment.

HEDIS MY 2021

1.05.2021 Utilization Measures & Enrollment by Product Line (ENP) Are members with unknown or third gender excluded from member months tables that only designate binary gender?

Yes. Members with unknown or non-binary gender are excluded from only the utilization measures that require a specific gender (male or female) and the ENP measure because this measure requires a gender to be assigned in the reporting tables. NCQA continues to track industry standards for non-binary gender.

*Originally posted on 11/16/2020, this FAQ was updated on 1/5/2021.  

HEDIS MY 2021

12.15.2020 Use of Opioids at High Dosage (HDO) The MLD Update Memo stated, “Add Acetaminophen Hydrocodone 7.5 MGPML Medications List to the Medication Lists column and 7.5 mg per mL to the Strength column.” However, this medication list is not included in the MLD (the MLD contains an Acetaminophen Hydrocodone 7.5 mg Medications List).

The MLD content is correct; the item in the MLD Update memo contains an error. Organizations should “Add Acetaminophen Hydrocodone 7.5 mg Medications List to the Medication Lists column and 7.5 mg to the Strength column.”

HEDIS MY 2021

12.15.2020 Controlling High Blood Pressure (CBP) & Comprehensive Diabetes Care (CDC) - BP control (<140/90 mm Hg) Is the use of average blood pressure readings allowed?

Yes, but only average readings that include separate values for systolic and diastolic blood pressure may be used for reporting.

HEDIS MY 2021

12.15.2020 Risk Adjusted Utilization Guideline 1 & Emergency Department Utilization (EDU) In the EDU measure, step 1 for the Calculation of Observed Events says to exclude ED visits that result in an inpatient stay or an observation stay. Should denied claims be used when looking for both an inpatient stay and an observation stay in this case?

Yes. When confirming that an ED visit does not result in an inpatient stay or an observation stay, all inpatient and observation stays must be considered, regardless of payment status (paid, suspended, pending, denied). Measure Certification will test this scenario to ensure all inpatient and observation stays are considered, regardless of payment status. For example, if an ED visit is paid but an inpatient stay is denied, the ED visit resulted in an inpatient stay and is not included in the Emergency Department Utilization measure when identifying observed ED visits.

HEDIS MY 2021

12.15.2020 Transitions of Care (TRC) May supplemental data be used for all four indicators in the Transitions of Care (TRC) measure?

Yes. Supplemental data may be used for all four indicators, including indicators that do not allow administrative reporting (Notification of Inpatient Admission and Receipt of Discharge Information).

Because there are no administrative codes to map to for the Notification of Inpatient Admission and Receipt of Discharge Information indicators, supplemental data must include all elements required by the measure's hybrid specifications for these indicators and once validated, the plan must determine how to get the results integrated for reporting. Plans should work with their vendors and this process should be reviewed and approved by the auditor.

HEDIS MY 2021

12.15.2020 Transitions of Care (TRC) Where in IDSS should supplemental data be reported when it is used for the Notification of Inpatient Admission and Receipt of Discharge Information indicators?

Supplemental data for Notification of Inpatient Admission and Receipt of Discharge Information indicators must be reported in the “Numerator events by supplemental data” data element in IDSS.

HEDIS MY 2021

11.16.2020 Emergency Department Utilization (EDU) Will the EDU measure be publicly reported in MY 2020?

No. The EDU measure was given first-year status for MY 2020 due to significant changes, including exclusion of high-frequency utilizers.

HEDIS MY 2021

11.16.2020 Transition of Care (TRC) For the Medication Reconciliation Post-Discharge indicator, documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review meets criteria. Does documentation of a post-op/surgery follow-up visit, without reference to the hospital stay, count as evidence that the provider is aware of the hospitalization?

No. Documentation of “post-op/surgery follow-up” without a reference to “hospitalization,” “admission” or “inpatient stay” does not imply there was a hospitalization and is not considered evidence that the provider was aware of the hospitalization.

HEDIS MY 2021

10.15.2020 Osteoporosis Screening in Older Women A dispensed dementia medication (Dementia Medications List) is listed as an exclusion in the eligible population. What time frame is required for the dispensing event?

The measure specification contains a formatting error and “A dispensed dementia medication (Dementia Medications List)” is intended to be a dash under the second bullet: “Any of the following during the measurement year or the year prior to the measurement year (count services that occur over both years).”

HEDIS MY 2021