HEDIS Quality Measure Toolkit
What is HEDIS®?
- HEDIS stands for Healthcare Effectiveness Data and Information Set.
- Developed by the National Committee for Quality Assurance (NCQA) in the 1980s.
- NCQA Specifications standardize performance to evaluate and compare health plan performance and quality.
- Contains 6 domains of care which are further divided into measures/sub-measures which include preventative care and condition specific care.
- Required for ongoing NCQA Health Plan accreditation.
How is HEDIS data collected?
Depending on the measure, data may be collected through:
- Administrative/claims data
- Supplemental files sent in by the provider during the year
- Medical record reviews
- Survey Method
- Electronic Clinical Data Systems (ECDS)
- Measure specifications outline measure description, exclusions and how the data may be collected.
View the General Guidelines and Measure Descriptions for best practice and measure tips.
HEDIS Measures
| Measure Name | Health Plan/Program | Eligibility |
|---|---|---|
| Adults’ Access to Preventative / Ambulatory Health Services (AAP) | Advantage MD, EHP, Priority Partners, USFHP | Members 20 years of age and older |
| Advance Care Planning (ACP) | Advantage MD, Dual Eligible Special Needs Plans (D-SNP) | Members 66 years of age and older |
| Antidepressant Medication Management (AMM) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 18 years of age and older |
| Appropriate Testing for Pharyngitis (CWP) | Advantage MD, EHP, Priority Partners, USFHP | Members 3 years of age and older |
| Asthma Medication Ratio (AMR) | EHP, Priority Partners/VBP, USFHP | Members 5–64 years of age |
| Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB) | Advantage MD, EHP, Priority Partners, USFHP | Members 3 months of age and older |
| Blood Pressure Control for Patients With Diabetes (BPD) | Advantage MD, EHP, Priority Partners/VBP, USFHP | Members 18–75 years of age |
| Breast Cancer Screening - E (BCS) | Advantage MD, EHP, Priority Partners, USFHP | Female Members 50–74 years of age |
| Care for Older Adults (COA) | Advantage MD, D-SNP | Members 66 years of age and older |
| Cervical Cancer Screening (CCS) | EHP, Priority Partners, USFHP | Female members 21–64 years of age |
| Child and Adolescent Well-Care Visits (WCV) | EHP, Priority Partners, USFHP | Member 3–21 years of age |
| Childhood Immunizations (CIS) and (CISE) | EHP, Priority Partners, USFHP | Children turning 2 years old in Measurement Year |
| Chlamydia Screening in Women (CHL) | EHP, Priority Partners, USFHP | Female members 16-24 years of age |
| Colorectal Cancer Screening (COL-E) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 45–75 years of age |
| Controlling High BP (CBP) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 18–85 years of age |
| Eye Exam for Patients With Diabetes (EED) | Advantage MD, EHP, Priority Partners, USFHP | Members 18–75 years of age |
| Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) | Advantage MD | Members 18 years of age and older |
| Follow-Up After Hospitalization for Mental Illness (FUH) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 6 years of age and older |
| Follow-Up Care for Children Prescribed ADHD Medication (ADD-E) | EHP, Priority Partners, USFHP | Members 6–12 years of age |
| Glycemic Status Assessment for Patients With Diabetes (GSD) | Advantage MD, EHP, Priority Partners/VBP, USFHP | Members 18–75 years of age |
| Immunizations for Adolescents (IMA) and (IMA-E) | EHP, Priority Partners, USFHP | Adolescents 13 years of age during the measurement year |
| Kidney Health Evaluation for Patients With Diabetes (KED) | Advantage MD, EHP, Priority Partners, USFHP | Members 18–75 years of age |
| Lead Screening in Children-HEDIS (LSC) | Priority Partners/VBP | Members 0–2 years of age |
| Lead Screening in Children-MDH (LSC) | Priority Partners/VBP | Members 12–23 months of age |
| Medication Adherence for Cholesterol (Statins) (MAC) | Advantage MD | Members 18 years of age or older |
| Medication Adherence for Diabetes Medications (MAD) | Advantage MD | Members 18 years of age or older |
| Medication Adherence for Hypertension (RAS antagonists) (MAH) | Advantage MD | Members 18 years of age or older |
| Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E) | EHP, Priority Partners, USFHP | Members 1–17 years of age |
| Osteoporosis Management in Women Who Had a Fracture (OMW) | Advantage MD, D-SNP | Women 67–85 years of age as of December 31st of the measurement year. |
| Osteoporosis Screening in Older Women (OSW) | Advantage MD | Women 65–75 years of age as of December 31st of the measurement year. |
| Pharmacotherapy Management of COPD Exacerbation (PCE) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 40 years of age and older |
| Plan All-Cause Readmission (PCR) | Advantage MD, D-SNP, EHP, Priority Partners, USFHP | Members 18 years of age and older |
| Prenatal and Postpartum Care (PPC) | EHP, Priority Partners/VBP, USFHP | Women who had a live birth(s) on or between 10/8 year prior to the measurement year and 10/7 of the measurement year. |
| Prenatal Immunization Status (PRS-E) | EHP, Priority Partners, USFHP | Pregnant members who deliver at >37 weeks during the measurement year |
| Risk of Continued Opioid Use (COU) | Advantage MD, EHP, Priority Partners/VBP, USFHP | Members 18 years of age or older |
| SSI Adults Ambulatory Care Visit (SSIA) | Priority Partners/VBP | Adults enrolled in a disabled coverage group (SSI) aged 21-64 years old |
| SSI Child Ambulatory Care Visit (SSIC) | Priority Partners/VBP | Children enrolled in a disabled coverage group (SSI) aged 0-20 years old |
| Statin Therapy for Patients with Cardiovascular Disease (SPC) | Advantage MD, EHP, Priority Partners, USFHP | Males 21–75 years of age. Females 40-75 years of age |
| Statin Therapy for Patients With Diabetes (SPD) | Advantage MD, EHP, Priority Partners, USFHP | Members 40–75 years of age |
| Statin Use in Persons With Diabetes (SUPD) | Advantage MD | Members with diabetes 40–75 years of age |
| Transitions of Care (TRC) | Advantage MD, D-SNP | Members 18 years of age and older |
| Use of First Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) | EHP, Priority Partners, USFHP | Members 1 - 17 years of age |
| Use of Imaging Studies for Low Back Pain (LBP) | Advantage MD, EHP, Priority Partners, and USFHP | Members 18 – 75 years of age |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) | EHP, Priority Partners, USFHP | Members 3–17 years of age |
| Well-Child Visits in the First 30 Months of Life (W30) | EHP, Priority Partners, USFHP | Member 15–30 months of age during measurement year |
Please contact your Provider Engagement Liaison or email [email protected] with any questions.
CPT codes are copyright 2023 American Medical Association. CPT is a registered trademark of the American Medical Association
COPYRIGHT NOTICE AND DISCLAIMER
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Anyone desiring to use or reproduce the materials without modification for an internal non-commercial purpose may do so without obtaining any approval from NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. All other uses, including a commercial use and/or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Reprinted with permission by NCQA. © 2023 NCQA, all rights reserved.
Limited proprietary coding is contained in the measure specifications for convenience. NCQA disclaims all liability for use or accuracy of any third-party code values contained in the specifications.
The American Medical Association holds a copyright to the CPT® codes contained in the measure specifications.
The American Hospital Association holds a copyright to the Uniform Billing Codes (“UB”) contained in the measure specifications. The UB Codes in the HEDIS specifications are included with the permission of the AHA. The UB Codes contained in the HEDIS specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting HEDIS measure results or using HEDIS measure results for their internal quality improvement purposes. All other uses of the UB Codes require a license from the AHA. Anyone desiring to use the UB Codes in a commercial product to generate HEDIS results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact [email protected].