“Number of Members in the Eligible Population” is calculated by IDSS. The shading in the data element table is correct. The step 5 instructions are incorrect and should indicate that this is a calculated field.
HEDIS 2019
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11.15.2018 Hospitalization for Potentially Preventable Complications On page 458 under step 5 there are instructions for how the number of members in the eligible population data element is reported in IDSS. It states, “Enter these values in the reporting table (HPC-A-3).” However, in that table, the column titled “Members in the Eligible Population” is shaded gray, indicating that it is calculated by IDSS. Is the data element reported by the organization, or calculated by IDSS?
11.15.2018 General Guidelines Do standard supplemental data files need to contain all data elements required by the hybrid specification, regardless of the method used by the plan to report the measure?
Yes. As stated in General Guideline 30, both standard and nonstandard supplemental data files must contain all data elements required by the hybrid specification, regardless of the reporting method used (administrative or hybrid). However, for HEDIS 2019, NCQA makes an exception for only standard supplemental data files and for only the Adult BMI Assessment (ABA) and Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) measures.
Because the values (height, weight) used to calculate BMI are often stored in EMRs and not included in data extracts, NCQA does not want to penalize plans for not having these data elements in their data files. Auditors may approve standard supplemental data files that include only the date and the BMI value or percentile.
For the WCC nutrition and physical activity counseling indicators, a date of service and an applicable code from the VSD counts as compliant.
NCQA is evaluating the standard supplemental data requirement for all other hybrid measures for HEDIS 2020.
HEDIS 2019
11.15.2018 All ECDS Measures What is Source of Payment (SOP) Typology?
The Source of Payment Typology was developed to create a standard for classifying payer type. In measure specifications, it will enhance identification of specific payer identity in clinical data used for NCQA reporting.
Modeled loosely after the ICD typology for classifying medical conditions, the SOP Typology identifies broad payer categories (step 2) with related subcategories that are more specific to a product (steps 3 and 4). The first digit of each code represents the organization providing the funds for care; subsequent digits provide more-specific information about the mechanism used to provide funds. This format provides the flexibility to either use payer codes at a highly detailed level or to roll up codes to broader categories for comparative analysis across payers and locations.
SOP Typology can be used by anyone to code the payment data source. Use of the payer classification may require a crosswalk of previous code lists to the new hierarchical payer typology.
Example steps for plan classification using SOP Typology:
1. Plan needing typology classification: Harvard Pilgrim Health
2. Determine main category for first digit: 5 (Commercial)
3. Determine subcategory for second digit: 1 (Managed Care Private)
4. Determine subcategory breakdown for third digit: 2 (PPO)
5. Assign final SOP classification code: 511 (Commercial Managed Care-HMO)
HEDIS 2019
11.15.2018 Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis If a member is included in the ART measure due to a rule-out diagnosis, may the member be removed from the denominator based on medical record documentation indicating an incorrect diagnosis of rheumatoid arthritis?
No. Members may not be removed from HEDIS measures due to billing errors. HEDIS does allow removal of “valid data errors” if they can be substantiated through medical record documentation; however, this applies only to hybrid measures. Because the ART measure is administrative only, the use of valid data errors is not permitted, nor may supplemental be used as a substitute for claims data (to correct billing errors) or to identify valid data errors.
HEDIS 2019
10.15.2018 Standardized Healthcare-Associated Infection Ration The HEDIS® 2019 Volume 2 Technical Specifications Update announced the suspension of the Standardized Healthcare-Associated Infection Ration (HAI) measure for all product lines. This change causes a discrepancy between the CMS Reporting Memo and HEDIS 2019 Volume 2 Technical Specifications. Will CMS clarify what must be reported for HEDIS 2019 for Medicare?
10.15.2018 Total Membership How should organizations handle dually enrolled members for the Total Membership (TLM) measure? Should organizations follow the "total unduplicated membership" rule, or should they follow General Guideline 15 and count the member twice (where applicable)?
Organizations should refer to General Guideline 15 in the HEDIS 2019 Volume 2 publication for guidance on reporting members with dual enrollment for the TLM measure. However, when General Guideline 15 allows members to be included in more than one product line deduplicate and count members only once in the measure as follows:
-Report members with dual Medicaid/Medicare enrollment in the Medicare product line.
–For other dual enrolled members report the members in the primary product line.
HEDIS 2019
10.15.2018 Plan All-Cause Readmissions Organizations are instructed to use the file run date to determine the member’s SES stratification in the last 3 months of the continuous enrollment period. For the PCR measure, the continuous enrollment period is 365 days prior to the Index Discharge Date through 30 days after that date. How is a member’s SES stratification determined if the run date falls after the end of the continuous enrollment period?
When determining the SES stratification for PCR, use the last month of the continuous enrollment period, regardless of the run date. For example, if the continuous enrollment period ends July 1, use May, June and July to assess the member’s SES stratification, regardless of the run date of the July Monthly Membership Detail Data File.
HEDIS 2019
10.15.2018 Required Exclusions Are members who are excluded because of hospice, advanced illness, frailty, Institutional SNP (I-SNP) or living long-term in an institution (LTI) included in the “Number of required exclusions” data element?
10.15.2018 Rules for Allowable Adjustments The General Guidelines in the Rules for Allowable Adjustments states, “use the separate HEDIS Adjustments VSD to calculate measure rates stemming from adjusted measure specification.” Does this mean that ONLY the HEDIS Adjustments VSD must be used?
No. The Allowable Adjustments VSD does not contain the standard HEDIS value sets; standard HEDIS value sets are in the HEDIS 2019 Volume 2 VSD. The Allowable Adjustments VSD includes only SNOMED and LOINC codes that are not in the Volume 2 VSD. Organizations collecting data using the rules for allowable adjustments can elect (but are not required) to use the value sets in the Allowable Adjustments VSD.
HEDIS 2019