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What is HEDIS used for?
The National Committee for Quality Assurance (NCQA) coordinates HEDIS testing and scorekeeping. The Centers for Medicare & Medicaid Services uses HEDIS scores to monitor a health plan’s performance. More than 90% of American health plans use HEDIS scores to compare how well the plan performs in eight areas of care.
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- Effectiveness of care
- Access to/availability of care
- Member satisfaction with the plan and providers or the experience of care
- Health plan stability
- Use of services
- Informed health care choices
- Cost of care
- Health plan descriptive information
We work with you to assure that all Department of Health (DOH) requirements concerning HEDIS performance measures are met on an ongoing basis. We do this by:
- Producing rates for all CHIP reporting measures
- Following NCQA specifications as outlined in the HEDIS Technical Specifications, clearly identifying the numerator and denominator for each measure.
- Validating HEDIS results by using an NCQA-licensed vendor
You can learn more about our quality initiatives by visiting our Quality Assurance and Performance Improvement (QAPI) program page.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveysCAHPS are a set of standardized surveys that assess patient satisfaction with the experience of care. CAHPS surveys are subsets of HEDIS reporting required by the DOH. We contract with an NCQA-certified vendor to administer the surveys according to HEDIS survey protocols. The surveys are based on randomly selected members and summarize satisfaction with the health care experience.
HEDIS incorporates a CAHPS survey of parental experiences with their children’s care. eChildren’s health care frequently requires different provider networks and addresses different consumer concerns (child growth and development, for example). We contract with a certified vendor to complete child CAHPS surveys and submit recipient-level data files to the NCQA for calculation of survey results.
HEDIS education materials
Here are some helpful links to get started with:
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2023 session dates coming soon.
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- Annual Percentage of Asthma Patients With One or More Asthma-Related Emergency Room Visits (PDF)
- Appropriate Treatment for Pharyngitis (CWP) (PDF)
- Appropriate Treatment for Upper Respiratory Infection (URI) (PDF)
- Asthma Medication Ratio (AMR) (PDF)
- Child and Adolescent Well Visit (WCV) (PDF)
- Childhood Immunization Status (CIS) (PDF)
- Chlamydia Screening in Women (CHL) (PDF)
- Contraceptive Care for All Women Ages 15-44 (CCW) (PDF)
- Contraceptive Care for Postpartum Women Ages 15-44 (CCP) (PDF)
- Developmental Screening in the First Three Years of Life (DVS) (PDF)
- Follow-Up After Hospitalization for Mental Illness (FUH) (PDF)
- Follow-Up Care for Children Prescribed ADHD Medication (ADD) (PDF)
- Identification of Alcohol and Other Drug Services (IAD) (PDF)
- Immunizations for Adolescents (IMA) (PDF)
- Lead Screening in Children (LSC) (PDF)
- Maternity: Prenatal and Postpartum Care (PPC) (PDF)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) (PDF)
- Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) (PDF)
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) (PDF)
- WellChild - First 30 months of Life (W30) (PDF)
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Measures in the HEDIS ECDS domain are specified for the electronic method of data collection.
Organizations may use several data sources to provide complete information about the quality of health services delivered to its members. Data systems that may be eligible for HEDIS ECDS reporting include, but are not limited to:
- Member eligibility files
- Electronic health records (EHRs)
- Clinical registries
- Health information exchanges (HIEs)
- Administrative claims systems
- Electronic laboratory reports (ELR)
- Electronic pharmacy systems
- Immunization information systems (IIS)
- Disease/case management registries
Data sources are categorized using the following criteria:
- Electronic health record (EHR): This data category includes information obtained directly from a patient as well as clinical findings generated as a result of samples collected from a patient (example: pathology and laboratory reports generated from entities not directly connected to the patient’s EHR).
- Health information exchanges (HIEs) and clinical registries eligible for this reporting category include state HIEs, immunization information systems (IIS), public health agency systems, regional HIEs (RHIO), Patient-Centered Data Homes™ or other registries developed for research or to support quality improvement and patient safety initiatives.
- HIEs used for ECDS reporting must use standard protocols to ensure security, privacy, data integrity, sender and receiver authentication and confirmation of delivery.
- Case management system: A shared database of member information collected through a collaborative process of member assessment, care planning, care coordination or monitoring of a member’s functional status and care experience. These systems include any system developed to support the organization’s case/disease management activities, including activities performed by delegates.
- Administrative: Includes data from administrative claim processing systems for all services incurred as well as member management files, member eligibility and enrollment files, electronic member rosters, internal audit files and member call service databases.
Each digital measure includes both the human readable technical documentation and the machine-readable files necessary for implementation.
Each HEDIS ECDS digital measure includes the following files:
- Measure-specific human readable file: Description of the measure specifications and requirements — to be used as a reference
- Expression logical model (ELM) files: These files are in a standard format and naming convention that should not be altered by either the MCO or health care provider. It is recommended that all files within a measure package are housed in the same place and naming conventions preserved, as the computer-readable files will reference the library files by name.
HEDIS ECDS measures reference single codes and value sets that must be used for HEDIS ECDS reporting. To administratively close gaps for ECDS measures, it is recommended you use the NCQA codes provided in the HEDIS specifications for each of the ECDS measures. The appropriate code for the measure you are reporting will be submitted as a “data criteria” (element level).
Quality measures
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- Healthy Beginnings Plus HEDIS reference guide (PDF)
- Telehealth billing guidelines (PDF)
- COVID-19 impact on HEDIS measure specifications (PDF)
- Billing guidelines & gap closure for VBS and HEDIS data capture (PDF)
- Newborn billing guidelines (PDF)
- Pediatric coding guide (PDF)
- Women’s health coding guide (PDF)
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).