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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.
|Measure Name||Health Plan/Program||Eligibility|
|Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis||EHP, Priority Partners, USFHP||Members 3 months of age and older|
|Follow up Care for Children Prescribed ADHD Medication||EHP, Priority Partners, USFHP||Members 6–12 years of age|
|Asthma Medication Ratio||Advantage MD, EHP, Priority Partners/VBP, USFHP||Members 5–64 years of age|
|Metabolic Monitoring for Children and Adolescents on Antipsychotics Total||EHP, Priority Partners, USFHP||Members 1–17 years of age|
|Breast Cancer Screening||Advantage MD, EHP, Priority Partners/VBP, USFHP||Members 50–74 years of age|
|Controlling High BP||Advantage MD, EHP, Priority Partners/VBP, USFHP||Members 18–85 years of age|
|Cervical Cancer Screening||EHP, Priority Partners, USFHP||Female members 21–64 years of age|
|Comprehensive Diabetes Care: Controlling High BP <140/90||Advantage MD, EHP, Priority Partners/VBP, USFHP||Members 18–75 years of age|
|Comprehensive Diabetes Care: Diabetic Eye Exam||Advantage MD, EHP, Priority Partners/VBP, USFHP|
|Comprehensive Diabetes Care: Diabetic HbA1c Test with Controlled Result||Advantage MD, EHP, Priority Partners/VBP, USFHP|
|Comprehensive Diabetes Care - Medical Attention for Nephropathy||Advantage MD||Members 18–75 years of age|
|Chlamydia Screening in Women||EHP, Priority Partners, USFHP|
|Childhood Immunizations||EHP, Priority Partners, USFHP|
|Colorectal Cancer Screening||Advantage MD, EHP, USFHP||Members 50–75 years of age|
|Appropriate Testing for Pharyngitis||EHP, Priority Partners, USFHP||Members 3 years of age and older|
|Follow-Up After Hospitalization for Mental Illness||Advantage MD, EHP, USFHP||Members 6 years of age and older|
|Immunizations for Adolescents||EHP, Priority Partners, USFHP||Adolescents 13 years of age during the measurement year|
|Lead Screening in Children-MDH||VBP||Members 12–23 months of age|
|Medication Adherence for Cholesterol (Statins)||Advantage MD||Members 18 years of age or older|
|Medication Adherence for Diabetes Medications||Advantage MD||Members 18 years of age or older|
|Medication Adherence for Hypertension (RAS antagonists)||Advantage MD||Members 18 years of age or older|
|Osteoporosis Management in Women Who Had a Fracture||Advantage MD||Women 67–85 years of age as of December 31st of the measurement year|
|Pharmacotherapy Management of COPD Exacerbation||Advantage MD, EHP, Priority Partners, USFHP|
|Prenatal and Postpartum Care||EHP, Priority Partners/VBP, USFHP|
|Statin Therapy for Patients with Cardiovascular Disease||Advantage MD, EHP, Priority Partners, USFHP||Males 21–75 years of age. Females 40-75 years of age|
|Statin Therapy for Patients With Diabetes||Advantage MD, EHP, Priority Partners, USFHP||Members 40–75 years of age|
|Use of Spirometry Testing in the Assessment and Diagnosis of COPD||Advantage MD, EHP, Priority Partners, USFHP|
|SSI Adults Ambulatory Care||VBP|
|SSI Children Ambulatory Care||VBP||Children 0-20 years of age|
|Statin Use in Persons With Diabetes||Advantage MD||Members with diabetes 40–75 years of age|
|Transitions of Care –Patient Engagement After Inpatient Discharge||Advantage MD / Provider Specialty: PCP, OCP||Members 18 years of age and older|
|Transitions of Care – Receipt of Discharge Information||Advantage MD / Provider Specialty: PCP, OCP||Members 18 years of age and older|
|Transitions of Care – Inpatient Notification||Advantage MD / Provider Specialty: PCP, OCP||Members 18 years of age and older|
|Transitions of Care– Medication Reconciliation Post-Discharge||Advantage MD||Members 18 years of age and older|
|Well-Child Visits in the First 30 Months of Life||Priority Partners/VBP||Member 15–30 months of age during measurement year|
|Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents||EHP, Priority Partners, USFHP||Members 3–17 years of age|
|Child and Adolescent Well-Care Visits||EHP, Priority Partners, USFHP||Member 3–21 years of age|
HbA1C Lab Test
- CPT: 83036, 83037
- CPT-CAT-II: 3044F, 3045F, 3046F
HbA1c Level Greater than/Equal to 7 and Less than 8
- CPT-CAT-II: 3051F
HbA1c Level Greater than/Equal to 8 and Less than/Equal to 9
- CPT-CAT-II: 3052F
HbA1C Greater than 9.0
- CPT: 83036, 83037
- CPT-CAT-II: 3046F
Please contact your Provider Engagement Representative or email ProviderEngagement@jhhc.com with any questions.