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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, USFHPMembers 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, USFHP 
Comprehensive Diabetes Care: Diabetic HbA1c Test with Controlled ResultAdvantage MD, EHP, Priority Partners/VBP, USFHP 
Comprehensive Diabetes Care - Medical Attention for NephropathyAdvantage MDMembers 18–75 years of age
Chlamydia Screening in WomenEHP, Priority Partners, USFHP 
Childhood ImmunizationsEHP, Priority Partners, USFHP 
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, USFHP 
Prenatal and Postpartum CareEHP, Priority Partners/VBP, USFHP 
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, USFHP 
SSI Adults Ambulatory CareVBP 
SSI Children Ambulatory CareVBPChildren 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

Measure Codes

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.