FAQ Directory: HEDIS

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1.16.2013 Medical Record Review Validation Can an auditor substitute one member in the MRRV sample of 16 if that members chart cannot be found?

Yes, substitution for one member is acceptable only if the organization cannot collect the chart because a practitioner is unable or unwilling to release it. The auditor has two options: he can select an original sample of 17 members (16 plus 1 oversample), and use the replacement member if the organization was unable to obtain a chart for one of the first 16 members, or he can send a 17th member when he is notified that one of the original 16 charts was unobtainable.

The auditors work papers should note which members chart was refused. If possible, the auditor should get a copy of the providers refusal letter or e-mail.

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

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 Medical Record Review Validation Can the plan choose to rotate a measure that failed MRR validation?

The intent of measure rotation is to reduce chart review, not be a means to select the best rate possible. However, NCQA does not specifically prohibit this approach. Please note, if the reason for failing can be seen as possibly affecting other measures in the group, the auditor may elect to review those other measures.

HEDIS 2013

1.16.2013 General Guidelines Is there a deadline for updating administrative rates with new sources of supplemental data?

Yes, the December Update included a modification to the audit timeline that requires all supplemental database activities be concluded by 5/1 in the reporting year. NCQA requires this deadline to allow sufficient time for audit review and possible corrections. The update should be made in the HEDIS Audit Timeline in Volume 5, on page 52 and in Volume 2, on page 17. This sentence should be added: "Auditor finalizes approval of Supplemental Databases, policies, procedures, and content (data)." by May 1.

HEDIS 2013

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 Medical Record Review Validation What happens if a plan doesnt report any measures in a group?

The auditor selects one measure from each measure group that applies to the health plan, and exclusions from the exclusions group. If the plan doesnt report any measures in a particular group, the auditor will use his discretion, based on past performance and current progress, to determine if an additional measure should be selected from a group already used.

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 What records are included in Group F (Exclusions)?

MRRV Group F (Exclusions) includes all optional and required exclusions and valid data errors found during medical record review. It does not include records excluded through administrative data or that belong to employees or their dependents. Other hybrid medical record exclusions that should not be reviewed in Group F are exclusions for CBP and the HbA1C Less Than 7% indicator. Because of the large volume, auditors review exclusion rates for these indicators separately. See the instructions in Volume 5, page 65 for reviewing CBP and HbA1c<7%.

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?

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

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