FAQ Directory: HEDIS

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12.14.2018 Appendix 3: PCP Definition May rural health centers be mapped to the PCP definition in Appendix 3 of Volume 2, similar to how Federally Qualified Heath Centers are handled?

No. Rural Health Clinics are not addressed in the updated PCP definition in Volume 2. All providers billing under the Rural Clinic facility codes must meet the definition of “PCP” in Appendix 3 in order to be included in the PCP-based HEDIS measures.

HEDIS 2019

12.14.2018 Hospitalization for Potentially Preventable Complications On page 453 of the HPC measure, the language for the first sentence in step 3 under “Chronic ACSC” is different than the language for the first sentence in step 3 under “Acute ACSC”. Is the difference in the language intentional?

No, the difference in the language is not intentional and the reference to “on the discharge claim” was unintentionally excluded. Step 3 for Acute ACSC should contain the same language as step 3 for chronic ACSC. In step 3 for ACSC, for the remaining acute inpatient and observation stay discharges, organizations should identify discharges with specified criteria on the discharge.

HEDIS 2019

12.14.2018 ECDS Must plans provide direct access of data to providers in order to meet the “data must be accessible to the care team” requirement in the ECDS general guidelines?

No. Plans do not need to be able to populate information directly into a provider EMR to meet this requirement. Plans can meet the requirement if they can provide requested information (phone, secure email, direct feed, provider portal, file request) to providers who are treating their members. Plans should have documented processes for providing information on how this works to be reviewed as part of the audit.

HEDIS 2019

12.14.2018 ECDS Are EMRs the best data source for HEDIS ECDS measures? Do they contain all the information needed to report the measures?

EMRs are limited in the amount of longitudinal information they contain for any one patient. Many data sources meet ECDS requirements. Plans have access to a wealth of information from across a much larger network than any single provider. ECDS is designed to encourage plans and providers to seek alternative sources of data (already being collected) to fill gaps in knowledge about a person’s health care experiences and future requirements.

HEDIS 2019

12.14.2018 ECDS May plans use administrative data (e.g., claims, enrollment) for ECDS reporting?

Yes. Plans may use administrative data to report HEDIS ECDS measures. Administrative data are a relevant data source and are one of four categories of data for ECDS reporting. If a plan’s administrative data files contain all the information it needs for a measure, it does not need additional data.

HEDIS 2019

12.14.2018 ECDS Who is considered part of the care team?

Any practitioner who provides care to or makes care decisions for or about a member’s care is part of the care team. Please note, if a measure has a practitioner type requirement the services required by the measure must still be performed by the appropriate practitioner type. However, the care team requirement for the data to qualify for ECDS reporting is not restricted by the practitioner type requirement.

HEDIS 2019

12.14.2018 ECDS Must a plan be fully integrated to report HEDIS ECDS measures?

No. Although this plan type may have a slight advantage in accessing medical records because of its integrated system, EMRs do not necessarily contain comprehensive information on individuals. Many other data sources qualify as ECDS data sources, and plans are encouraged to utilize every reliable source of member data.

HEDIS 2019

12.14.2018 Identification of Alcohol and Other Drug Services and Mental Health Utilization In the “Any Service” category, how should we count members who have had eligible services in different age groups?

Categorize members in the “Any Services” category based on their age as of the first eligible encounter in any service category.

HEDIS 2019

11.15.2018 Transitions of Care When reporting the Patient Engagement After Inpatient Discharge indicator, if the member is unable to communicate with the provider, does an interaction between the member’s caregiver and the provider meet criteria?

Yes, if the interaction meets criteria based on the measure specifications. The caregiver is not required to be designated as the patient’s legal guardian for the interaction to count toward the measure.  

HEDIS 2019

11.15.2018 Transitions of Care When reporting Notification of Inpatient Admission and Receipt of Discharge Information indicators using an integrated EMR system, is a “received date” required in the EMR if the information was in the shared EMR on the day of admission/discharge or on the following day?

No. With a shared EMR, evidence that the information was filed/accessible by the PCP or ongoing care provider on the day of admission/discharge or the following day meets criteria for Notification of Inpatient Admission and Receipt of Discharge Information indicators. The organization is not required to find additional notation of a “received date” if it is evident that the information was in the shared EMR on the day of admission/discharge or the following day.

HEDIS 2019

11.15.2018 SES Guidelines To calculate a member’s SES stratification, the instructions say to evaluate whether the member’s LIS values (item 35) are the same or different in the last 3 months of continuous enrollment (CE). How do you determine if a value is the same or different?

A value is different if it is either < or = 0 OR > 0. For the last 3 months of the CE period:

  • Count the member as receiving an LIS payment if 2 of the last 3 months are >0, even if the values are different.
           Example:
           October       LIS = 35
           November   LIS = 40
           December   LIS = -35
  • Count the member as NOT receiving an LIS payment if 2 of the last 3 months are < or = 0, even if the values are different.
          Example:
          October       LIS = 0
          November   LIS = -35
          December   LIS = 35

 

HEDIS 2019

11.15.2018 Transitions of Care When reporting Receipt of Discharge Information, if the PCP or ongoing care provider is the discharging provider, are the requirements the same to meet numerator criteria?

Yes. When the PCP or ongoing care provider is the discharging provider, they must document the required discharge information specified in the measure. This must be done in the patient's outpatient medical record on the day of discharge or on the following day.

HEDIS 2019