FAQ Directory: HEDIS

It is up to the organization to ensure that multiple mammograph episodes are the same event if they occur on the same date of service. HEDIS measure certification assumes events on the same day are different mammograms. If evidence shows the mammography episodes are the same, count only one. Organizations should develop their own methods and apply them consistently when reporting.

HEDIS MY 2025

No. Each mammogram requires a unique BIRADS assessment (e.g., two mammograms need two separate BIRADS to meet numerator criteria). A single documented BIRADS assessment dated on or within 14 days (15 days total) of multiple mammography episodes does not meet criteria for multiple denominator events.

DBM-E sample and test decks have been updated and re-posted. If you already received a status of “pass” for a DBM-E test deck, the status has been re-set and you must run the updated deck to certify. The deadline to certify the measure will be extended to July 31 so organizations can accommodate this update.

HEDIS MY 2025

Yes. One follow-up event may meet criteria for multiple BIRADS assessments. Each BIRADS assessment counts as separate denominator events, and requires the appropriate follow-up to count toward the numerator. However, one breast biopsy may meet criteria for multiple high-risk BIRADS assessments, and one mammogram or ultrasound may meet criteria for multiple inconclusive BIRADS assessments.

HEDIS MY 2025

Yes. This data element is a calculated field in IDSS, and it should be shaded gray. We will correct this in the release of the MY 2026 Volume 2 Technical Specifications.

HEDIS MY 2025

Yes. As described in Numerator 5—Immunization Status: Hepatitis B, use POS code 81 to exclude laboratory claims when identifying members with a history of hepatitis B illness. POS code 81 was mistakenly omitted from the Direct Reference Code tab of the VSD. Because the information needed for reporting is in the measure specification, NCQA does not intend to reissue the VSD.

HEDIS MY 2025

Yes. If the HPV or Pap test sample source is vaginal, and can be billed to an appropriate code in the value sets, it may be used to meet criteria.

HEDIS MY 2025

No. The codes are for “amitriptyline hydrochloride 25 MG/chlordiazepoxide 10 MG Oral Tablet.” They belong only in the Chlordiazepoxide 10 MG Medications List. NCQA re-released the MY 2025 Medication List directory on May 15, 2025, to incorporate this update. NCQA’s Measure Certification program confirmed that certification organizations deleted the codes from the Chlordiazepoxide 25 MG Medications List. No changes to the current process are necessary.

HEDIS MY 2025

An error was identified in the HEDIS MY 2024 Medication List Directory (released on April 1, 2024). For the Asthma Medication Ratio (AMR) measure, “package size” and “unit” are required to perform calculations. If we cannot find package size and unit for NDC codes, we cannot include the codes in the AMR medication lists. For the MY 2024 Update release of the MLD, an alternative method was used to identify package size and unit so more codes could be included in the medication lists. Because this method resulted in incorrect information, we removed these codes from 11 medication lists.

• Albuterol Medications
• Asthma Controller and Reliever Medications
• Beclomethasone Medications
• Budesonide Formoterol Medications
• Budesonide Medications
• Ciclesonide Medications
• Fluticasone Medications
• Fluticasone Salmeterol Medications
• Formoterol Mometasone Medications
• Levalbuterol Medications
• Mometasone Medications

Three medication lists were removed from the AMR measure.

• Fluticasone Furoate Umeclidinium Vilanterol Medications
• Salmeterol Medications
• Tiotropium Medications

Customers who purchased the HEDIS MY 2024 Medication List Directory should re-download the file from the My Downloads section of their My NCQA account. Customers who purchased a product that contains the AMR measure specification should delete the three medication lists, consistent with how changes from the technical update are applied.

HEDIS MY 2024

No. Documents produced using the C-CDA standard are structured summaries or snapshots of information used to facilitate data exchange. They are not eligible as proof of service for HEDIS MY 2024, and should not be used for medical record review abstraction.  

HEDIS MY 2024

NCQA will remove the RAND table from the Guidelines for Calculations and Sampling with the release of the HEDIS MY 2025 Technical Update on March 31, 2025. Future releases of the HEDIS Volume 2: Technical Specifications for Health Plans publication will not contain a RAND table.

Beginning MY 2025, NCQA will use an alternative timeline and approach to distribute RAND numbers for HEDIS reporting. This information will be released in the NCQA store for purchasers of HEDIS Volume 2 in the November before production of systematic samples for hybrid reporting (e.g., November 2025, for MY 2025).  

Organizations participating in NCQA’s Measure Certification program will receive separate guidance on how NCQA will accommodate this change for certification of systematic sampling logic.

HEDIS MY 2025

Common themes include:

• Clinical accountability for the information.
  An arrangement may exist where a provider, such as a PharmD, interacts with members to collect information on their last colorectal cancer screening or breast cancer screening. It is unclear if a PharmD has the appropriate clinical training to document the complete context of the service or interpret the information being shared. Nor is it evident that a PharmD would be clinically accountable for that aspect of the member’s care (preventive cancer care).

Another arrangement that may exist includes workflows where providers (e.g., NPs, PAs) contact a plan’s membership annually to assess a member’s medical history, including when they received their last cancer screenings. It is unclear if a singular touchpoint by the NP/PA indicates that the provider has clinical accountability for the member’s care. Organizations are not allowed to call members to collect data.

• Including and maintaining information in the health record.
  A member’s health record should be accessible to the member and the care team responsible for that aspect of their care. Systems that are internal-facing only to a plan do not represent a source of data that contribute to an individual’s ongoing clinical care. Further, an individual’s health record should be available to them to reference or share with a care team in the future.

HEDIS MY 2025

HEDIS Volume 2 provides guidance in several places:

• Member-reported services and biometric values general guideline.
  This general guideline states that member-reported services may be used only if collected by a primary care practitioner or specialist (if the specialist is providing a primary care service related to the condition being assessed, in the course of taking a member’s history), and if the information is included in the member’s health record.
• Supplemental data general guideline.
  Information on services reported by members often reside in non-standard supplemental sources. The supplemental data general guideline states that there must be evidence of provider accountability for the information documented. The guideline also states that documentation of member-reported services must be complete (e.g., date, place of service, procedure, prescription, test result or finding, practitioner type).
• Electronic Clinical Data Systems general guidelines.
  Organizations may develop workflows that result in documentation of member-reported services. A common example is documentation in systems identified as case management. The ECDS general guideline states that case management systems are shared, meaning that there is bidirectional access to the data. These data would be accessible to members and to members’ care teams for care coordination and planning.

HEDIS MY 2025