FAQ Directory: HEDIS

No. Each inpatient hospital stay does not need to be both acute and observation for direct transfer. When assessing for direct transfer, include those with acute inpatient to acute inpatient, observation to observation, acute inpatient to observation and observation to acute inpatient.

This applies to both MY 2026 and MY 2025

HEDIS MY 2026

Members with an unknown or nonbinary gender do not qualify for the risk adjusted utilization measures (PCR, HFS, HFC, HFG, HFO, HFU, AHU, EDU, HPC, EDH) because these measures require a gender to assign age/gender weights. These members should be removed from the measures.

This is not a change; measure models have always included male and female weights. The use of the administrative gender codes for MY 2026 clarify which members are included in the initial population.

HEDIS MY 2026

Yes. The HEDIS MY 2026 Technical Update will remove HCPCS G0136 from the measure’s screening numerators and remove ICD-10 Z codes from the measure’s intervention denominators. The measure will continue to rely on LOINC codes for documentation of standard screenings and positive screening results. Additionally, NCQA will update some intervention procedure value sets to align with current code lists.

HEDIS MY 2026

The Volume 2 BCS-E specification identifies the data elements for the SES stratification in Data Element Table BCS-E-B-3. Although the table includes a data element for “Total,” a Total will not be included for SES stratifications when the IDSS is released.

This discrepancy will not affect organizations reporting BCS-E through the IDSS, because “Totals” are calculated values in the IDSS and are not included in an organization’s XML file.

The IDSS will not calculate a “Total” for the SES stratification; a “Total” is already calculated from the age stratifications, and would be redundant.

HEDIS MY 2025

Any coded response (any non-null response—positive or negative) on a pre-specified instrument for food, housing and transportation counts for completed screening numerators (numerators 1, 3, 5), with the exception of the PRAPARE Food Insecurity Instrument question (LOINC code 93031-3). Based on how the question is structured and responses are coded, a “No” or “None of the above” response cannot be coded, and must be left null; thus, a null response meets criteria for this item only. 

HEDIS MY 2026

No. The PHQ-A is a different tool than the PHQ-9M, and is not included in Depression Screening and Follow-Up for Adolescents and Adults (DSF-E), Prenatal Depression Screening and Follow-Up (PND-E) and Postpartum Depression Screening and Follow-Up (PDS-E).

Plans may map appropriate screenings and results from any pre-specified tool to the LOINC codes in the specifications. If the core 9 questions in the PHQ-A are the same as those in the PHQ-9M, the same LOINC may be mapped.

Auditors review all code mapping as part of the annual review.

HEDIS MY 2026

Yes. Given the audit’s current and future importance, NCQA will use the HEDIS MY 2026 Technical Update to add program information to the Volume 2 publication.

This information resides in HEDIS Volume 5 and the Audit Program Code of Conduct. Adding it to Volume 2 enhances the information’s accessibility for all organizations participating in HEDIS.

Anticipate additional information in the following Volume 2 sections:  

NCQA HEDIS Compliance Audit Program Description

• References to the standardized HEDIS Compliance Audit methodology: All Licensed Organizations and Certified HEDIS Compliance Auditors use this method without deviation. All health plans reporting HEDIS are held to the same standards and requirements in HEDIS Volume 5. 
• References to the strict requirements for audit independence: All Licensed Organizations and auditors must avoid conflicts of interest, including perceived conflicts of interest, and are prohibited from providing technical assistance or advisory services to organizations that they audit. Noncompliance may result in revocation of licensure and certification status.

General Guideline: Preparing for the Audit

• A description of supplemental data validation: Information will summarize requirements and timing for all supplemental data sources undergoing validation. 
• A description of preliminary rate review: Information will summarize requirements for preliminary rate submission through the IDSS, and emphasize expectations for organizations to substantiate changes in performance rates.

HEDIS MY 2026

Member-reported data are allowed in specific scenarios, and when all requirements are met.

Organizations may not call members to collect HEDIS data. The expectation is that member-reported data are generated during an encounter where the member receives care.   

Some HEDIS data are reported by members; for example, when standardized assessment tools are used (e.g., PHQ-2), or when documenting language preference, race and ethnicity.  

Services and biometric values reported by members are permitted if they adhere to the following guidelines in HEDIS Volume 2:

• Member-Reported Services and Biometric Values general guideline. Member-reported services may be used if collected by a PCP 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 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. Documentation of member-reported services must be complete (date, place of service, procedure, prescription, test result or finding, practitioner type).

HEDIS MY 2026

Provider attestations or portal data are allowed in specific scenarios and when all requirements are met.

Organizations may obtain information from providers on services that were rendered via attestation forms or provider portal interfaces. These are considered supplemental sources, and must be substantiated with proof-of-service documentation (e.g., original medical record).

In particular, organizations may not use provider attestations or data entered in an electronic platform as evidence that a service was rendered (i.e., as proof of service). This includes attestation forms filed in the member’s record, which are not primary sources for the information.

HEDIS MY 2026

The following data elements must be present for pharmacy data:

• Generic name (or brand name).
• Strength/dose.
• Route.
• Dispensed or shipped date (i.e., the date when the medication was dispensed or shipped).

Medical record documentation that an individual was prescribed a medication, or that lists current/active medications, does not meet criteria. The dispensed date is required. For mailed prescriptions, the shipped date is considered the dispensed date.  

HEDIS MY 2026

Proof of service is the primary source documentation for a service or a result (not a secondary representation of the information), and should originate from the source system where it was first documented.

Acceptable proof of service:

• A copy of the information from the member’s chart from the service provider or PCP.
• A copy of the clinical report or clinical summary from the visit for service, such as lab or radiology reports.
• A screen shot of the EHR records or state- or county-sponsored immunization registry records.

Proof of service is primary source documentation, not a secondary representation of that information. The following provide examples that are not considered proof of service:

• C-CDA or FHIR files are electronically generated, and are not proof of service. 
• Attestation forms are not the original source of documentation for an encounter, and are not proof of a service or result. 

HEDIS MY 2026

No. BPD-E will not be publicly reporting for MY 2026; NCQA will allow voluntary ECDS reporting for BPD-E. The administrative and hybrid version of the BPD measure will continue to be publicly reported for MY 2026.

HEDIS MY 2026