FAQ Directory: HEDIS

Yes, if a person in denominator 2 is 12 years of age at the start of the measurement period and received tobacco cessation counseling within the 180 days prior to the measurement period at 11 years of age, this person is compliant for numerator 2.

This clarification will be included in the HEDIS Volume 2 MY 2026 Technical Update, scheduled for release on March 31, 2026.

HEDIS MY 2026

No. C-CDA documents cannot be used for these purposes as the documents are electronically generated and not the same as the medical record documented in the primary source system where care was originally recorded (e.g. electronic medical record). This includes C-CDA documents received from HIEs.

HIEs support the exchange of clinical information, an important function for the delivery of care. Organizations are encouraged to use electronic files received from an HIE, such as electronic C-CDA or FHIR documents (e.g., C-CDA XML, FHIR JSON), as a supplemental data source.

HEDIS MY 2026

No, pharmacotherapy interventions provided to persons aged 17 years and younger at the time of the dispensing event do not count towards numerator 2 because there are no current FDA-approved tobacco cessation medications for persons under 18 years of age. If a person in denominator 2 is 18 years of age at the start of the measurement period and received pharmacotherapy interventions within the 180 days prior to the measurement period at 17 years of age, this person is not compliant with numerator 2.  

This clarification will be included in the HEDIS Volume 2 MY 2026 Technical Update, scheduled for release on March 31, 2026.

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

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

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

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

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