FAQ Directory: HEDIS

Per General Guideline 32, there are two ways to apply exclusions after samples have been pulled and chart review has begun. Because the sample must be reproducible, the members remain in the eligible population but are removed from the sample and reflected in the denominator. Organizations should indicate the exclusions by reporting them as the number of administrative data records excluded. When the population is larger than the MRSS, replace those members with members from the oversample.

Remember that the denominator is used to calculate and report the measure. All exclusions and replacements are reflected in the denominator calculation. The following are examples:

Example 1:
Eligible population = 300
MRSS = 300
Oversample Rate = 0%
Oversample Records Number = 0
Number of administrative data records excluded = 3
Oversample Records Added = 0
Denominator = 297

Example 2:
Eligible population = 5,800
MRSS = 411
Oversample Rate = 5%
Oversample Record Number = 21
Number of administrative data records excluded = 11
Oversample Records Added = 11
Denominator = 411

HEDIS MY 2022

Per General Guideline 32, there are two ways to apply exclusions after samples have been pulled and chart review has begun. Because the sample must be reproducible, the members remain in the eligible population but are removed from the sample and reflected in the denominator. Organizations should indicate the exclusions by reporting them as the number of administrative data records excluded. When the population is larger than the MRSS, replace those members with members from the oversample.

Remember that the denominator is used to calculate and report the measure. All exclusions and replacements are reflected in the denominator calculation. The following are examples:

Example 1:
Eligible population = 300
MRSS = 300
Oversample Rate = 0%
Oversample Records Number = 0
Number of administrative data records excluded = 3
Oversample Records Added = 0
Denominator = 297

Example 2:
Eligible population = 5,800
MRSS = 411
Oversample Rate = 5%
Oversample Record Number = 21
Number of administrative data records excluded = 11
Oversample Records Added = 11
Denominator = 411

HEDIS MY 2021

No. Documentation of an “unknown” eye exam result does not meet criteria for hybrid reporting for the eye exam indicator of the CDC measure or the EED measure.

HEDIS MY 2022

The guideline for deceased members (General Guideline 18) is a member-level exclusion. For episode-based measures, if one event does not meet numerator criteria, and the organization chooses to use this optional exclusion, remove all member events/episodes from the measure.

HEDIS MY 2021

No. Documentation of an “unknown” eye exam result does not meet criteria for hybrid reporting for the eye exam indicator of the CDC measure or the EED measure.

HEDIS MY 2021

Yes. NCQA DAV data may be used as standard supplemental data if the auditor receives a completed current year’s Roadmap Section 5 from the reporting entity using the data. The Roadmap must explain how data from the validated DAV entity is transferred to the reporting entity and what the entity does to the data. The Roadmap is completed by the health plan; no documentation is required from the DAV entity except for the final list of validated ingestion sites and clusters, along with the date they were approved. If the reporting entity processes the validated CCD in any way after receipt, the auditor must validate the file back to the original validated CCD to ensure that no data were changed.
If an NCQA-validated DAV entity includes data from an unvalidated data cluster, the auditor must validate that data, following the nonstandard supplemental data guidelines, before the data can be used for HEDIS reporting. The auditor may not perform PSV on any validated data files.
The NCQA DAV data definition will be included in General Guideline 31 for MY 2022.

HEDIS MY 2021

Yes. Remove the SOC that reads, “Revised the Reporting Instructions for the ‘NumeratorByAdminElig’ data element in Table WCC-1/2 to read ‘For each Metric and Stratification.’” Organizations reported “NumeratorByAdminElig” by age stratification in the past, so this is not a change to the measure for MY 2020 & MY 2021 reporting.

HEDIS MY 2022

Yes. Remove the SOC text that reads, “Revised the Reporting Instructions for the ‘NumeratorByAdminElig’ data element in Table TRC-3: Data Elements for Transitions of Care to ‘For each Metric and Stratification.’” Organizations reported “NumeratorByAdminElig” by age stratification in the past, so this is not a change to the measure for MY 2020 & MY 2021 reporting.

HEDIS MY 2022

Yes. Remove the SOC that reads, “Revised the Reporting Instructions for the ‘NumeratorByAdminElig’ data element in Table WCC-1/2 to read ‘For each Metric and Stratification.’” Organizations reported “NumeratorByAdminElig” by age stratification in the past, so this is not a change to the measure for MY 2020 & MY 2021 reporting.

HEDIS MY 2021

Yes. Remove the SOC text that reads, “Revised the Reporting Instructions for the ‘NumeratorByAdminElig’ data element in Table TRC-3: Data Elements for Transitions of Care to ‘For each Metric and Stratification.’” Organizations reported “NumeratorByAdminElig” by age stratification in the past, so this is not a change to the measure for MY 2020 & MY 2021 reporting.

HEDIS MY 2021

No. The number of numerator events by administrative data in eligible population, the number of required exclusions and the current year’s administrative rate data elements must remain frozen at the time of sampling and do not change with data refresh.

HEDIS MY 2021

No. The number of numerator events by administrative data in eligible population, the number of required exclusions and the current year’s administrative rate data elements must remain frozen at the time of sampling and do not change with data refresh.

HEDIS MY 2022