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Quality Improvement and HEDIS

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Tip Sheets

HEDIS® Guides

Quality Measures:

Healthcare Effectiveness Data and Information Set (HEDIS)

The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, Carolina Complete Health is accountable for the timeliness and quality of healthcare services (including acute, preventive, and mental health) delivered to its diverse membership.

Use of HEDIS Scores

As both state and federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician-specific scores are being used as evidence of preventive care from primary care office practices.

Calculating HEDIS Rates

HEDIS rates can be calculated in two ways: with administrative data or hybrid data.

Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to primary care provider services, and utilization of acute and mental health services.

Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care, and well-child care.


As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment, or healthcare operations is permitted by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate with Carolina Complete Health, which allows them to collect PHI on our behalf.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Page Last Updated: 06/11/2024