FAQ Directory: HEDIS

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2.15.2024 Provider Interaction with Admission/Discharge Information in the Medical Record for the Transitions of Care Measure For the Notification of Inpatient Admission and Receipt of Discharge Information indicators, is evidence that the provider reviewed the admission/discharge information required (i.e., is the provider required to sign or acknowledge the admission/discharge information after it is filed in the outpatient medical record)?

No. Evidence that the PCP or ongoing care provider reviewed the admission/discharge information is not required for these indicators. If the required information is filed in the outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the required time frame, this alone meets criteria.

HEDIS MY 2024

2.15.2024 ADT Feeds for the Transitions of Care Measure Does an admission notification documented in an ADT feed meet criteria for the Notification of Inpatient Admission and Receipt of Discharge Information indicators?

No. Admission/discharge notifications in the ADT alone do not meet criteria (even if the provider has access to the ADT) because ADTs are not considered the legal medical record.
Criteria are met if the provider documents ADT notifications in the appropriate outpatient medical record or shared EMR (accessible to the PCP or ongoing care provider) during the time frame specified in the measure.

HEDIS MY 2024

2.15.2024 FI-SNPs, HI-SNPs, IE-SNPs and HEDIS Reporting Are Facility-Based Institutional SNPs (FI-SNPs), Hybrid Institutional SNPs (HI-SNPs) and Institutional Equivalent-SNPs (IE-SNPs) treated the same as I-SNPs when reporting HEDIS?

Yes. FI-SNPs, HI-SNPs and IE-SNPs should be treated the same as I-SNPs for reporting. Because they are all types of I-SNPs, they are included in the I-SNP exclusion, and are excluded when
I-SNPs are excluded.

HEDIS MY 2024

1.16.2024 3-Dose-Series Prevnar 20 Pneumococcal Vaccine for Childhood Immunization Status (CIS) When will PCV20 pneumococcal vaccine be added to the pneumococcal conjugate value sets?

We anticipate that PCV20 will be added to the CIS value sets in the HEDIS MY 2024 Technical Update, scheduled for release on April 1, 2024.
Although the PCV20 vaccine is not included in the measure for MY 2023, NCQA does not anticipate this will impact performance. The measure denominator only includes children who were at least 18 months old and expected to have already completed the pneumococcal series by June 2023 (the month when ACIP recommended PCV20).

HEDIS MY 2024

11.16.2023 Definition of “Unknown” reporting category for race and ethnicity values When can organizations report race and ethnicity as an “Unknown” value?

“Unknown” race and ethnicity values indicate missing data. Two criteria must be met to report “Unknown”:

1. There is no recorded value, and

2. The organization did not receive a declined response from the member.

Starting in MY 2023, all “Unknown” values must be attributed to an unknown data source. This is a change from MY 2022, when “Unknown” values were attributed to an indirect data source.

HEDIS MY 2023

11.16.2023 MY 2023 Race and Ethnicity Stratification (RES) HEDIS Compliance Audit Requirements Are there new audit requirements for race and ethnicity stratification reporting for MY 2023?

No. Volume 5: HEDIS Compliance Audit MY 2023 does not include new requirements for reporting race and ethnicity. Consistent with MY 2022, these data are addressed in the HEDIS Roadmap. Auditors must confirm that organizations provide a complete Roadmap response, and review all attachments describing data flow, layout and transformation. Roadmap Section 6, Question 6.3J requires organizations to describe the sources they use, their processes for disaggregating race and ethnicity fields, their data source reconciliation and prioritization processes and the percentage of members with available data.

NCQA introduced a direct data threshold of ≥20% for Race/Ethnicity Diversity of Membership (RDM) in the 2024 Health Plan Ratings scoring methodology. Please note that this is independent from the race and ethnicity stratifications, and should not impact audit designations. There are no bias thresholds for the race and ethnicity stratifications in Volume 5.

HEDIS MY 2023

11.16.2023 Sources with populated race or ethnicity values of “Unknown” or “Two or More Races” How should organizations handle data sources with values of “Unknown” or “Two or More Races”?”

NCQA strongly discourages using “Unknown” and “Two or More Races” response categories when collecting race and ethnicity data. When possible, organizations should instead use and encourage alternatives such as:

“Other” or “None of the above” response options for members who are unsure of their race or ethnicity.
The ability to select multiple race values for members with two or more races.

If “Unknown” or “Two or More Races” are populated values in sources where health plans cannot improve response terms/options, they can be mapped to the “Some Other Race” reporting category.

HEDIS MY 2023

11.16.2023 Data source for “Asked But No Answer” reporting category To what data source should organizations attribute the “Asked But No Answer” race and ethnicity reporting category?

The “Asked But No Answer” reporting category reflects members who were asked for race or ethnicity data, but who declined to provide a response. This reporting category must be attributed to a direct data source because the members self-reported by declining to answer.

HEDIS MY 2023

11.15.2023 Codes for Race and Ethnicity Stratification (RES) Are LOINC codes used to identify race and ethnicity?

No. Codes to identify race and ethnicity resemble some LOINC codes (i.e., the same format), but are derived from a code system developed by the U.S. Centers for Disease Control and Prevention (CDC).
The code is the same across terminologies in multiple instances. NCQA recommends that organizations establish data quality controls to avoid inadvertent data reporting errors. For example, “2106-3” could result in errors if used incorrectly:

2106-3 = “White” (CDC Race and Ethnicity).
2106-3 = “Choriogonadotropin (pregnancy test) [Presence] in Urine” (LOINC).

HEDIS MY 2024

11.15.2023 HEDIS Roadmap Documentation Requirements for Aggregators What HEDIS Compliance Audit Roadmap documentation is required by health plans for data sources provided from an aggregator (e.g., health information exchange)?

It depends:

For data streams provided by aggregators with a current approved validation status in the NCQA Data Aggregator Validation program, only Roadmap Section 5 from the plan is required.
For all other data streams provided by aggregators that are not validated in the DAV program, a Roadmap Section 5 from the plan and Section 5a from the aggregator are required.

NCQA maintains an online directory of entities with validated data streams.

HEDIS MY 2024

11.15.2023 Members Recommended for Routine Cervical Cancer Screening The Cervical Cancer Screening (CCS and CCS-E) measures include the following criteria to identify members recommended for routine cervical cancer screening:
• Administrative Gender of Female (AdministrativeGender code F) any time in the member’s history.
• Sex Assigned at Birth (LOINC code 76689-9) of Female (LOINC code LA3-6) any time in the member’s history.
• Sex Parameter for Clinical Use of Female (SexParameterForClinicalUse code Female-typical) during the measurement year.
What data sources can be used to identify these members?

When reporting CCS-E, all three methods may be used, using any data source. When reporting CCS, use only administrative data (Administrative Gender of Female [AdministrativeGender code F] any time in the member’s history) to determine members recommended for routine cervical cancer screening.
Where supplemental data may be used for CCS remains the same for MY 2024. Supplemental data may not be used for denominator criteria, except in required exclusions.

HEDIS MY 2024

11.15.2023 Excluding Laboratory Claims (Claims with POS Code 81) Will instructions to exclude laboratory claims (claims with POS code 81) be added to additional measures and value sets in the Technical Update memo?

Yes. We anticipate the laboratory claim exclusion will be added to the following measures and value sets in the Technical Update memo:
AMR:    Step 2 of the event/diagnosis (Asthma Value Set)
GSD:    Numerators (HbA1c Test Result or Finding Value Set)
EED:     Event/diagnosis (Diabetes Value Set)
OMW:   Step 2 of the event/diagnosis (Fractures Value Set)
SSD:     Numerator (HbA1c Test Result or Finding Value Set)
SMD:    Numerator (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
SMC:    Numerator (LDL-C Test Result or Finding Value Set)
IET:      Step 2 of the event/diagnosis (Alcohol Abuse and Dependence Value Set; Opioid Abuse and Dependence Value Set; Other Drug Abuse and Dependence Value Set)
APM-E: Numerators (HbA1c Test Result or Finding Value Set; LDL-C Test Result or Finding Value Set)
DSF-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Depression Value Set)
DMS-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
DRR-E: Exclusions 1 (Bipolar Disorder Value Set; Other Bipolar Disorder Value Set; Personality Disorder Value Set; Psychotic Disorders Value Set; Pervasive Developmental Disorder Value Set)
ASF-E: Exclusions 1 (Alcohol Use Disorder Value Set; Dementia Value Set)

HEDIS MY 2024