FAQ Directory: HEDIS

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1.16.2013 Medical Record Review Validation Can auditors provide plans with the measures selected for over-read earlier than May 1? What if the plan finishes MRR earlier?

The current timeline says that the auditor selects the measures for review on May 1 and not before; however, if the auditor reviews the health plans internal timelines, and finds that the plan expects to finish MRR early, it is acceptable that the auditor send the measure list when all chart review is complete and he has received a final count of numerator hits for each hybrid measure. For example, if the plan finishes all chart chases on April 29 and provides the numerator count lists, the auditor can select the measures for validation and start the process early.

Note: If the auditor allows for an earlier MRRV timeline, the plan may have to adjust other deadlines affected by this change.

HEDIS 2013

1.16.2013 General Guidelines Can Health plans collect data from charts for a supplemental database and use the results for administrative rates?

Looking at charts is one way to collect data for a supplemental database (note: this activity should be distinguished from and not include chart review activities for the hybrid measures). All data in the supplement database, regardless of how it was collected, should be treated as administrative data. With the exception of standard data sources such as EHRs and state registries, supplemental databases should not be used during chart review for the hybrid measures.

HEDIS 2013

1.16.2013 General Guidelines Should Medicare Advantage (MA) members who elect the hospice benefit and choose to remain enrolled in the MA plan be excluded from MA HEDIS denominators?

No, not for HEDIS 2013 reporting; however, beginning with HEDIS 2014, exclude MA members who elect the hospice benefit available through original Medicare. This change will be in the HEDIS 2014 Volume 2 specifications.

HEDIS 2013

1.16.2013 Medical Record Review Validation For measures that are heavily or entirely reliant on MRR data (e.g., COA, ABA, WCC, CDC BPs), if an organization attempts MRR validation and fails, or is able to retrieve a only small percentage of charts, can they report an administrative rate as low as 0% (assuming no other issues are identified)?

A low administrative rate, even 0%, can be reported, if the plan wants to submit such a rate and the auditor finds no bias or other problems in the administrative process.

HEDIS 2013

12.16.2012 Guidelines for Relative Resource Use Measures The table under step 9 on page 350 of the HEDIS 2013 Volume 2 should be used when assigning members to a RRU risk group. This year, the final risk score is rounded to 4 decimal places. In the table, Risk Group 1 is between 0.0000 and 0.2490. Risk Group 2 is between 0.2500 and 0.4990. To which risk group should a member be assigned whose risk score is 0.2495? The score does not fall in either group.

All the last digits of "0" in the table should be replaced with "9" for the upper score. For example, Risk Group 1 should be revised so it is between 0.0000 and 0.2499. A score of 0.2495 should be assigned to group 1.

HEDIS 2013

12.16.2012 General Guidelines Some cells in the HEDIS 2013 Pharmacy Standard Pricing Table (SPT-Pharm) include dashes (-) instead of prices. Are the dashes equivalent to $0.00?

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia In the Volume 2 Technical Update, the Continuous Enrollment criteria were revised to read "the measurement year and the year prior to the measurement year." Should the Allowable Gap criteria also include the year prior to the measurement year?

Yes. Members should have no more than one gap in enrollment of up to 45 days during each year of continuous enrollment.

HEDIS 2013

11.16.2012 Care for Older Adults May a yes/no checklist be used for the advance care planning indicator?

If "yes" is checked, it may be counted as evidence that the member executed an advance care plan. If "no" is checked, evidence of an advance care planning discussion must be documented. A checklist does not count as evidence of a discussion.

HEDIS 2013

11.16.2012 Race/Ethnicity Diversity of Membership The note below table RDM-C-1/2/3 indicates that the "Unknown" category includes only members for whom the organization has not sought direct or indirect race/ethnicity information. If an organization sought this information but could not obtain it from the member, is this included in the "Unknown" category?

Yes. The Unknown category should be used in cases when the organization did not obtain race/ethnicity information using the direct or indirect data collection method or did not receive a "Decline" response. If the plan attempted to collect the information and the member gave a "Decline" response, the member is counted in the Direct Data Collection percentages (because the plan asked about the members race/ethnicity and received a response). The plan receives credit for attempting to collect the information, even though the member refused to provide it.

HEDIS 2013

11.16.2012 Medication Reconciliation Post-Discharge If a member's discharge is followed by a readmission or direct transfer to a nursing home or long term care facility, is the discharge included in the measure's denominator?

If there is evidence that the member remained in the nursing home or long-term care facility through December 1 of the measurement year, the discharge must be excluded from the denominator. If there is evidence that the member was discharged from the nursing home or long term care facility by December 1 of the measurement year, the discharge must be included in the denominator. Organizations may not assume that the member remained in a nursing home or long-term care facility through the end of the measurement year, based solely on the discharge status; there must be a method for identifying the members status for the remainder of the measurement year.

HEDIS 2013

11.16.2012 Use of High-Risk Medications in the Elderly When calculating the Average Daily Dose for medications in Table DAE-C, should organizations use rounding rules before comparing the dose to the specified threshold? How should organizations calculate average daily dose for elixirs and concentrates?

Organizations should not round when calculating average daily dose. To calculate average daily dose for elixirs and concentrates multiply the volume dispensed by dose and divide by days supply.

HEDIS 2013

11.16.2012 Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia The CMC event/diagnosis criteria were revised in the Volume 2 Technical Update to include both facility and professional claims when identifying an AMI or CABG event. Should both facility and professional claims be included when identifying AMI or CABG for the SMC measure?

Yes. Organizations should include AMI and CABG from inpatient claims only, but may use both facility and professional claims to identify these events for HEDIS 2013 reporting.

HEDIS 2013