FAQ Directory: HEDIS

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11.15.2017 Supplemental Data Is it acceptable to flag records in a supplemental data file as paid or denied when there is no payment attached to the records in the file?

No. It is not acceptable to classify a supplemental data source as paid or denied unless it is known whether the data in the data source were paid or denied. This is especially true when the data are being used for measures that require claims payment statuses (e.g. LBP, NCS). Organizations should not assume services were denied services just because there isn't a payment status associated with them. For measures where payment status is required, the auditor must be able to validate that the payment status is accurate.

HEDIS 2018

11.15.2017 Weeks of Pregnancy at Time of Enrollment The HEDIS 2018 Volume 2 Technical Update memo includes a RAND number for the “Weeks of Pregnancy at Time of Enrollment” measure. Is this correct?

No. “Weeks of Pregnancy at Time of Enrollment (WOP)” was retired in HEDIS 2017; the RAND number was inadvertently included in the HEDIS 2018 Volume 2 Technical Update memo.

HEDIS 2018

11.15.2017 Guidelines for Calculations and Sampling The footnote on page 45 of HEDIS 2018 Volume 2 indicates that the lowest Prior Year rate from “Prenatal and Postpartum Care” and “Frequency of Prenatal Care” should be used to reduce the sample size for PPC. Given that FPC was retired with the HEDIS 2018 Volume 2 Technical Update, should the PPC MRSS use the lower rate of the Postpartum and Prenatal care indicators?

Yes. With the retirement of the FPC measure, organizations may reduce the sample size for the PPC measure using the lowest rate of the 2 indicators from the current year’s administrative rate or the prior year’s audited, product line-specific rate.

HEDIS 2018

11.15.2017 Use of Opioids at High Dosage In the HEDIS 2018 Volume 2 Technical Update memo Table UOD-A includes a variable ranging from 4-12 for the MED Conversion Factor for methadone based on mg/day of methadone used. However, in the HEDIS 2018 NDC MLD Directory all NDCs for Methadone under the medication list "Opioid Medication" have a MED Conversion Factor (column M) of 3. For performing the MED calculation in UOD, which MED Conversion Factor should be used for methadone?

For HEDIS 2018 reporting, for methadone, the MED conversion factor of "3" should be used as listed in the NDC list; not the factors listed in Table UOD-A. We will reevaluate using the sliding scale conversion factors for HEDIS 2019.

HEDIS 2018

11.15.2017 Reporting Requirements The HEDIS 2018 Volume 2 Technical Update memo announced the retirement of “Annual Monitoring for Patients on Persistent Medications (MPM)” for Medicare and the name change from “Inpatient Hospital Utilization (IHU)” to “Acute Hospital Utilization (AHU).” This caused a discrepancy between the CMS Reporting Memo and HEDIS 2018 Volume 2 Technical Specifications. Will CMS release a clarification on what must be reported for HEDIS 2018 for Medicare?

Yes. CMS released a clarification on October 11, 2017, through HPMS, announcing that MPM was retired and is not required for HEDIS 2018 reporting; it also clarified that “Inpatient Hospital Utilization” is now “Acute Hospital Utilization” and should be reported as the updated measure. If you have additional questions, contact CMS at HEDISquestions@cms.hhs.gov.

HEDIS 2018

11.15.2017 Hospitalization for Potentially Preventable Complications On Page 37 of the HEDIS 2018 Volume 2 Technical Update memo, the “Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers” and “Number of Chronic ACSC Outliers and Acute ACSC Outliers” reporting categories have the same description.
Should the first reporting category listed above state ‘non-outlier’ instead of ‘outlier’?

Yes; the specifications should read “Reporting: Number of Chronic ACSC Non-Outliers and Acute ACSC Non-Outliers:The number of chronic ACSC non-outlier members and the number of acute ACSC non-outliers for each age and gender group and the overall total.”

HEDIS 2018

11.15.2017 Transitions of Care The HEDIS 2018 Volume 2 Technical Update memo indicates the following change in the Transitions of Care specifications: In the first sentence of the third paragraph, replace “date/time” with “date.”
Should this change also apply to the first bullet in the “Note” section of the technical specifications that reads, “The following notations or examples of documentation do not count as numerator compliant:
*Documentation of notification that does not include a time frame or date/time stamp.”

Yes. Replace the reference to “date/time” in the first bullet in the Note section with “date.”

HEDIS 2018

10.15.2017 ECDS What does NCQA mean by “information has to be accessible by the health care team at the point of care”?

To qualify for HEDIS ECDS reporting, practitioners and practitioner groups that are accountable for clinical services provided to members must have access to data used by plans for quality measure reporting, regardless of the SSoR.

NCQA does not currently specify a method of data access, but a core principle of ECDS reporting is that the information needed to deliver the highest-quality care must be available to the entire health care team responsible for managing a member’s health.

Qualifying modes of access may be as simple as a provider’s phone request for member information, or as sophisticated as an integrated decision support system. The care team’s ability to access data must be documented, to provide evidence that information is available whether or not it is accessed.

HEDIS 2018

10.15.2017 ECDS What HEDIS Effectiveness of Care measures will move to ECDS?

NCQA is evaluating existing HEDIS measures, eCQMs and other de novo measure concepts for inclusion in the ECDS domain. Selected measures will be reengineered and retested, as necessary, and must be approved by the CPM before their release in ECDS, consistent with other HEDIS measures.

HEDIS 2018

10.15.2017 Transitions of Care Please clarify the September 15 FAQ stating that SNPs and MMPs are not required to report the TRC measure because it does not appear in Table 3 of the CMS reporting requirements memo. Are SNP and MMPs plans required to report TRC in their contract-level submission?

Yes. Contracts that offer SNP and MMP plan benefit packages are required to report TRC in their contract-level submission, as described in Table 2 of the CMS HEDIS 2018 Reporting Requirements memo.

HEDIS 2018

10.15.2017 Unhealthy Alcohol Use Screening and Follow-Up In the updated measure specification that was released with the HEDIS 2018 Volume 2 Technical Update, the Data Elements table includes a stratification for ages 44-64. Should this age stratification be 45-64?

Yes. The correct age stratifications are 18-44, 45-64, 65+.

HEDIS 2018

10.15.2017 Use of Opioids at High Dosage and Use of Opioids From Multiple Providers Step 2 of the UOD and UOP eligible population states to exclude “members who had only a single opioid medication (Opioid Medications List) dispensing event.” Does a member who had multiple prescriptions (for the same or different medications) on the same date of service (with no prescriptions on other dates of service during the measurement year) meet criteria for exclusion?

Yes. The intent is to exclude members who were dispensed opioids on only one date of service during the measurement year. If the member had multiple prescriptions (for the same or different medication) on one date of service and had no opioid prescriptions on another date of service during the measurement year, the member is excluded.

HEDIS 2018