FAQ Directory: HEDIS for the Quality Rating System

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9.30.2015 QRS and Off-Market Commercial HEDIS Submission Should Off-Marketplace plans include their membership in QRS and in Marketplace accreditation?

No. Off-Marketplace plans should include its membership in its commercial HEDIS submission and in its commercial product line when submitting for health plan accreditation.


3.19.2015 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Is QRS Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) collected using the hybrid method or the administrative method?

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life should be reported using only the administrative methodology as specified in the 2015 QRS Technical Specifications (http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf). Hybrid specifications are not available for this measure in the QRS.  The W34 measure is listed as a measure in the sample size table of the QRS Sampling Guidelines and was a misprint which will be corrected in the 2016 QRS Measure Technical Specification.
For organizations who have started medical record review for W34, please note, the IDSS will only accept the administrative elements of the measure for QRS.


2.26.2015 Relative Resource Use for People With Diabetes In the Quality Ratings System (QRS) Measure Technical Specifications, the RRU General Guidelines reference 13 risk groups, but there are only 8 risk groups referenced in Table RDI-B-4: Data Elements for Relative Resource Use for People With Diabetes. Which is correct?

Table RDI-B-4 should include all 13 risk groups, to match the RRU General Guidelines in the QRS technical specifications.


12.22.2014 QRS and Commercial HEDIS Submission Should off-Marketplace enrollees in a QHP, be included in an organization’s NCQA HEDIS commercial submission?

For 2015, QHP enrollees as defined by CMS should not be included in an organization’s NCQA HEDIS commercial submission; they should only be included in the organization’s QRS submission. However, if an organization has already completed programming, NCQA understands that off-Marketplace enrollees in a QHP may have been excluded from the QRS submission. In these instances, these enrollees should be included in the organization’s NCQA HEDIS commercial submission.

With regard to requirements for reporting enrollee survey results and HEDIS measure results, NCQA plans to accept results that follow CMS reporting requirements. NCQA will review CMS beta-test results in fall 2015 before making final decisions on Accreditation reporting requirements for 2016.

For 2015, NCQA HEDIS commercial submissions (which may include off-Marketplace enrollees) will be used to score commercial health plan accreditation (HPA). HEDIS submissions are not required for Marketplace HPA scoring in 2015.


12.15.2014 CAHPS Health Plan Survey 5.0H, Child & Adult Version Has the CAHPS survey sample frame validation process changed?

Yes. Starting in reporting year 2015, NCQA requires that all Licensed Organizations apply a password lock to the validated and approved sample frame file used for conducting the commercial and Medicaid Child and Adult CAHPS and the Qualified Health Plan (QHP) Enrollee surveys. Survey vendors may not pull a sample from an unlocked file.


5.15.2014 Marketplace How will HEDIS work with the Marketplace products?

For Marketplace (Exchange) products, HEDIS will follow the federal Marketplace Quality Rating System (QRS). CMS will release QRS measure specifications and reporting guidelines (including HEDIS) in September 2014.