HEDIS Compliance Audit Certification

The Healthcare Effectiveness Data and Information Set (HEDIS®) is widely used to measure and improve health care quality and is relied on by government regulators, health plans, provider organizations, employers and others to identify quality and compare plan performance.

The accuracy of collecting, measuring and reporting HEDIS is vital to benchmarking and improving quality. The HEDIS Compliance Audit™ helps ensure accurate, reliable data that can be used by employers, consumers and government to compare health plans.

NCQA licenses organizations and certifies individuals affiliated with licensed organizations to conduct audits using NCQA’s standardized audit methodology. Auditors use the first half of the audit, the overall IS review, to identify data areas to focus on during the second half of the review (HEDIS Compliance Standards). This allows for customization of each audit depending on the individual health plan’s strengths and weaknesses. The audit adds a higher degree of integrity to HEDIS data, and enables organizations to provide consumers and purchasers with consistent and comparable HEDIS results.

About the Audit

In 1995 NCQA convened the HEDIS Audit Committee, which developed a precise, standardized method to verify the integrity of HEDIS collection and calculation processes: the NCQA HEDIS Compliance Audit. The audit is in two parts: evaluating a plan’s overall information systems capabilities (the “IS standards”) and evaluating a plan’s ability to comply with HEDIS specifications (the “HD standards”).

All health plans submitting HEDIS data to NCQA must undergo a HEDIS Compliance Audit, which may only be performed by licensed organizations and certified auditors. Certifying auditors and licensing qualified organizations helps verify that standard auditing methods are used during all NCQA HEDIS Compliance Audits.

Licensed HEDIS Compliance Audit Organizations

NCQA licenses organizations that perform HEDIS Compliance Audits to ensure that audits comply with standard methods.

Certified HEDIS Compliance Auditors

To become a HEDIS Compliance Auditor, you must be employed by, or contract with, a licensed HEDIS Compliance Audit Organization.

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