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Quality Measure Toolkit

What is HEDIS®?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It’s a set of standard performance measures that gives information about the quality of a health plan. Patients and providers can find out about the quality of care, access, cost, and other measures to compare managed care plans. The Centers for Medicare & Medicaid Services (CMS) collects HEDIS data for Medicare plans.

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
  • 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 NameHealth Plan/ProgramEligibility
Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisEHP, Priority Partners, USFHPMembers 3 months of age and older
Follow up Care for Children Prescribed ADHD MedicationEHP, Priority Partners, USFHPMembers 6–12 years of age
Asthma Medication RatioAdvantage MD, EHP, Priority Partners/VBP, USFHPMembers 5–64 years of age
Metabolic Monitoring for Children and Adolescents on Antipsychotics TotalEHP, Priority Partners, USFHPMembers 1–17 years of age
Breast Cancer ScreeningAdvantage MD, EHP, Priority Partners/VBP, USFHPFemale Members 50–74 years of age
Controlling High BPAdvantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–85 years of age
Cervical Cancer ScreeningEHP, Priority Partners, USFHPFemale members 21–64 years of age
Comprehensive Diabetes Care: Controlling High BP <140/90Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Comprehensive Diabetes Care: Diabetic Eye ExamAdvantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Comprehensive Diabetes Care: Diabetic HbA1c Test with Controlled ResultAdvantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Comprehensive Diabetes Care - Medical Attention for NephropathyAdvantage MDMembers 18–75 years of age
Chlamydia Screening in WomenEHP, Priority Partners, USFHPFemale members 16-24 years of age
Childhood ImmunizationsEHP, Priority Partners, USFHPChildren turning 2 years old  in Measurement Year
Colorectal Cancer ScreeningAdvantage MD, EHP, USFHPMembers 50–75 years of age
Appropriate Testing for PharyngitisEHP, Priority Partners, USFHPMembers 3 years of age and older
Follow-Up After Hospitalization for Mental IllnessAdvantage MD, EHP, USFHPMembers 6 years of age and older
Immunizations for AdolescentsEHP, Priority Partners, USFHPAdolescents 13 years of age during the measurement year
Lead Screening in Children-MDHVBPMembers 12–23 months of age
Medication Adherence for Cholesterol (Statins)Advantage MDMembers 18 years of age or older
Medication Adherence for Diabetes MedicationsAdvantage MDMembers 18 years of age or older
Medication Adherence for Hypertension (RAS antagonists)Advantage MDMembers 18 years of age or older
Osteoporosis Management in Women Who Had a FractureAdvantage MDWomen 67–85 years of age as of December 31st of the measurement year
Pharmacotherapy Management of COPD ExacerbationAdvantage MD, EHP, Priority Partners, USFHPMembers 40 years of age and older
Prenatal and Postpartum CareEHP, Priority Partners/VBP, USFHPWomen who had a live birth(s) on or between 10/8 year prior to the measurement year and 10/7 of the measurement year.
Statin Therapy for Patients with Cardiovascular DiseaseAdvantage MD, EHP, Priority Partners, USFHPMales 21–75 years of age. Females 40-75 years of age
Statin Therapy for Patients With DiabetesAdvantage MD, EHP, Priority Partners, USFHPMembers 40–75 years of age
Use of Spirometry Testing in the Assessment and Diagnosis of COPDAdvantage MD, EHP, Priority Partners, USFHPMembers 40 years of age and older
SSI Adults Ambulatory CareVBPDisabled SSI Adults 21-64 years old
SSI Children Ambulatory CareVBPDisabled SSI Children 0-20 years of age
Statin Use in Persons With DiabetesAdvantage MDMembers with diabetes 40–75 years of age
Transitions of Care –Patient Engagement After Inpatient DischargeAdvantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Transitions of Care – Receipt of Discharge InformationAdvantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Transitions of Care – Inpatient NotificationAdvantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Transitions of Care– Medication Reconciliation Post-DischargeAdvantage MDMembers 18 years of age and older
Well-Child Visits in the First 30 Months of LifePriority Partners/VBPMember 15–30 months of age during measurement year
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/AdolescentsEHP, Priority Partners, USFHPMembers 3–17 years of age
Child and Adolescent Well-Care VisitsEHP, Priority Partners, USFHPMember 3–21 years of age

 

Please contact your Provider Engagement Representative or email ProviderEngagement@jhhc.com with any questions.

CPT codes are copyright 2019 American Medical Association. CPT is a registered trademark of the American Medical Association

COPYRIGHT NOTICE AND DISCLAIMER

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. © 2020 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 ub04@aha.org.