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FAQ Directory: HEDIS

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10.15.2019 Organization Responsibility for Chart Review HEDIS 2020 clarified that chart pursuit is recommended but is determined by the organization. Does this mean that chart pursuit is up to the organization?

Yes. Although NCQA recommends that organizations using the Hybrid Method pursue charts for all noncompliant members in the systematic sample, ultimately, the decision is the organization’s.

HEDIS 2020

10.15.2019 “Unknown” SES Category The SES stratification guidance in HEDIS 2020 Volume 2 indicates that the “Unknown” category may be used for only Puerto Rico plans or if the auditor approves a small number of unassigned members. Is there a specific number of Unknown members a plan is allowed to report?

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be at or below 1%. If more than 1% of eligible members are assigned to the “Unknown” category, the plan must work with the auditor to identify why members are being categorized as “Unknown.”

HEDIS 2020

10.15.2019 Medication Dispensed Date If pharmacy data are classified as supplemental and the medication dispensed date is not documented, may the “shipped date” be used as the “dispensed date”?

No. The “shipped date” may not be used as “dispensed date” date when reporting the pharmacy measures.

HEDIS 2020

10.15.2019 Pharmacy Data and Medication Samples If pharmacy data are classified as supplemental, may the date when a provider gives free medication samples to a member be considered the “dispensed date”?

Yes. The date when the provider gives the medical sample to the member is considered the “dispensed date” when reporting pharmacy measures.
 

HEDIS 2020

10.15.2019 Codes Found in Medical Records For General Guideline 31: Supplemental Data, does removal of the hybrid data elements requirement mean that codes found in the medical record may be used as proof of service even if there is no additional documentation of the service provided?

No. Codes alone (without additional documentation of the service provided) do not meet criteria for proof of service. If a provider performs a service, it is expected that additional documentation exists in the medical record or in the primary source document. Auditors must validate, through primary source verification, all elements required by the administrative measure specification.

HEDIS 2020

10.15.2019 Reporting of the Initial Population by Data Source A bullet in the Summary of Changes in the DRR, AIS and PRS measures states: Removed the collection of the “Initial Population” and “Denominator” data elements by SSoR in the Data Elements for Reporting tables. This contradicts the Data Elements tables of all three measures, which has the initial population reported by data source. Is the SOC correct?

No. Replace the language with: Removed the collection of the “Denominator” data element by SSoR in the Data Elements for Reporting tables. The Data Elements tables are correct for the DRR, AIS and PRS measures and the initial population is reported by data source.

HEDIS 2020

10.15.2019 General Guideline 18: Deceased Members Is General Guideline 18: Deceased Members an optional exclusion? Must a deceased member be removed from all HEDIS measures?

The exclusion in General Guideline 18 is optional. Members who die during the measurement year may be excluded from all measures, except the measures in the Health Plan Descriptive domain or the Risk Adjusted Utilization subdomain. However, if a member dies during the measurement year, the organization is not required to remove the member from all measures.
For example, if an organization identifies a deceased member during medical record review for the ABA measure, the member may be removed from the measure as a valid data error and replaced with a member from the oversample, but the organization is not required to remove the member from all other applicable HEDIS measures.
Additionally, there is no requirement to assess numerator compliance for deceased members and exclude the member only if they are not numerator compliant. NCQA does not prescribe how organizations identify deceased members using claim/encounter and enrollment data. Organizations must develop their own methods to identify these members.

HEDIS 2020

10.15.2019 Supplemental Data and Rules for Allowable Adjustments In some cases, supplemental data are not allowed for regular HEDIS reporting, but may supplemental data sources be used when following the Rules for Allowable Adjustments?

Yes. Supplemental data may be used for the denominator and the numerator when following the Rules for Allowable Adjustments. In general, the data are usable when the codes are in the value sets and the clinical intent of the measure is not changed, but there are restrictions for use of supplemental data in regular HEDIS reporting:

  1. For denominator calculation. The current restriction in regular HEDIS reporting is based on auditability, not on the data’s effect on the measure’s clinical intent. In Allowable Adjustments, files may be used if they meet all measure requirements.
  2. For Numerator calculation. The current restriction in regular HEDIS reporting is based on assessing paid claims vs. denied claims. In Allowable Adjustments, files may be used if they meet all requirements of the measure, even if the organization cannot determine payment status.

HEDIS 2020

9.16.2019 Cutoff Date for NDCs in the HEDIS 2020 MLD What is the cutoff date for including National Drug Codes (NDCs) in the HEDIS 2020 Medication List Directory (MLD)?

Any NDC or RxNorm code that is in the U.S. National Library of Medicine’s RxNorm database as of September 1, 2019 will be considered for inclusion in the HEDIS 2020 MLD, which will be posted to the NCQA website on November 1, 2019. This is a change from past years’ cutoff date, which was September 30.

HEDIS 2020

4.15.2019 SES Guidance in Technical Update The SES stratification guidance in the HEDIS 2019 Volume 2 Technical Update Memo indicates that the “Unknown” category may be used for only Puerto Rico plans or if the auditor approves a small number of unassigned members. Is there a specific number of Unknown members a plan is allowed to report?

Except for plans in Puerto Rico, which report all members in the “Unknown” category, it is expected that the member count in this category will be fewer than 10. Plans should determine why members are reported as “Unknown” and be able to explain the reason to their auditor.

This category should not be used for members who are disenrolled for the 2019 calendar year and consequently have no record in the December 2018 Monthly Membership Detail File. Use the October and November files for these members.

HEDIS 2019

4.15.2019 No Benefit Designation How does an organization determine if the No Benefit designation is appropriate for reporting?

General Guideline 25 in HEDIS Volume 2 explains that benefits are not assessed at the service level. Assessment of benefits must follow the measure specifications under the Benefit section of the Eligible Population criteria. Organizations may not assess benefits at a service level for an NB (No Benefit) audit designation. 

For example:

·    If the organization offers a pharmacy benefit but does not cover a specific medication class, the member has a pharmacy benefit and is included in the applicable measures requiring this benefit.

·    If the organization offers a mental health benefit but does not cover inpatient visits, the member has a mental health benefit and is included in the applicable measures requiring this benefit, unless the measure benefit requires inpatient care, per the Eligible Population benefit requirements (e.g., Follow-up After Hospitalization for Mental Illness requires both inpatient and outpatient mental health coverage).

HEDIS 2019

2.15.2019 Plan All-Cause Readmissions (PCR) The “Total” data elements for Medicare in Table PCR-C must match the “Total Medicare” data elements in Table PCR-D. Are organizations required to report the totals in both tables?

No. Organizations only need to report the “Total” data elements for Medicare in Table PCR-C. Remove the “Total Medicare” row from Table PCR-D that is used for the SES Stratifications. The duplicate data elements were removed in the Interactive Data Support System (IDSS) and the data will only be collected in Table PCR-C. The asterisked language may also be removed under these two tables.

HEDIS 2019