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Quality Measure Toolkit

What is HEDIS®?

  • HEDIS stands for Healthcare Effectiveness Data and Information Set.
  • NCQA Specifications standardize performance to evaluate and compare health plan performance and quality.   
  • 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
  • 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
Appropriate Testing for Pharyngitis (CWP)EHP, Priority Partners, USFHPMembers 3 years of age and older
Asthma Medication Ratio (AMR)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 5–64 years of age
Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)EHP, Priority Partners, USFHPMembers 3 months of age and older
Blood Pressure Control for Patients With Diabetes (BPD)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Breast Cancer Screening (BCS)Advantage MD, EHP, Priority Partners, USFHPFemale Members 50–74 years of age
Care for Older Adults (COA)Advantage MD Special Needs PlanMembers 66 years of age and older
Cervical Cancer Screening (CCS)EHP, Priority Partners, USFHPFemale members 21–64 years of age
Child and Adolescent Well-Care Visits (WCV)EHP, Priority Partners, USFHPMember 3–21 years of age
Childhood Immunizations (CIS)EHP, Priority Partners, USFHPChildren turning 2 years old  in Measurement Year
Chlamydia Screening in Women (CHL)EHP, Priority Partners, USFHPFemale members 16-24 years of age
Colorectal Cancer Screening (COL)Advantage MD, EHP, USFHPMembers 50–75 years of age
Controlling High BP (CBP)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–85 years of age
Eye Exam for Patients With Diabetes (EED)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Follow-Up After Hospitalization for Mental Illness (FUH)Advantage MD, EHP, USFHPMembers 6 years of age and older
Follow-Up Care for Children Prescribed ADHD Medication (ADD)EHP, Priority Partners, USFHPMembers 6–12 years of age
Hemoglobin A1c Control for Patients With Diabetes (HBD)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18–75 years of age
Immunizations for Adolescents (IMA)EHP, Priority Partners, USFHPAdolescents 13 years of age during the measurement year
Kidney Health Evaluation for Patients With Diabetes (KED)Advantage MDMembers 18–75 years of age
Lead Screening in Children-HEDIS (LSC)EHP, Priority Partners, USFHPMembers 0–2 years of age
Lead Screening in Children-MDH (LSC)VBPMembers 12–23 months of age
Medication Adherence for Cholesterol (Statins) (MAC)Advantage MDMembers 18 years of age or older
Medication Adherence for Diabetes Medications (MAD)Advantage MDMembers 18 years of age or older
Medication Adherence for Hypertension (RAS antagonists) (MAH)Advantage MDMembers 18 years of age or older
Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)EHP, Priority Partners, USFHPMembers 1–17 years of age
Osteoporosis Management in Women Who Had a Fracture (OMW)Advantage MDWomen 67–85 years of age as of December 31st of the measurement year
Pharmacotherapy Management of COPD Exacerbation (PCE)Advantage MD, EHP, Priority Partners, USFHPMembers 40 years of age and older
Prenatal and Postpartum Care (PPC)EHP, 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.
Risk of Continued Opioid Use (COU)Advantage MD, EHP, Priority Partners/VBP, USFHPMembers 18 years of age or older
SSI Adults Ambulatory Care (SSIAJH)VBPDisabled SSI Adults 21-64 years old
SSI Children Ambulatory Care (SSICJH)VBPDisabled SSI Children 0-20 years of age
Statin Therapy for Patients with Cardiovascular Disease (SPC)Advantage MD, EHP, Priority Partners, USFHPMales 21–75 years of age. Females 40-75 years of age
Statin Therapy for Patients With Diabetes (SPD)Advantage MD, EHP, Priority Partners, USFHPMembers 40–75 years of age
Statin Use in Persons With Diabetes (SUPD)Advantage MDMembers with diabetes 40–75 years of age
Transitions of Care – Inpatient Notification (TRC)Advantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Transitions of Care – Medication Reconciliation Post-Discharge (TRC)Advantage MDMembers 18 years of age and older
Transitions of Care – Patient Engagement After Inpatient Discharge (TRC)Advantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Transitions of Care – Receipt of Discharge Information (TRC)Advantage MD / Provider Specialty: PCP, OCPMembers 18 years of age and older
Use of Imaging Studies for Low Back Pain (LBP)Advantage MD, EHP, Priority Partners, and USFHPMembers 18 – 75 years of age
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)Advantage MD, EHP, Priority Partners, USFHPMembers 40 years of age and older
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)EHP, Priority Partners, USFHPMembers 3–17 years of age
Well-Child Visits in the First 30 Months of Life (W30)Priority Partners/VBPMember 15–30 months of age during measurement year

 

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

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. © 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.