Quality Improvement and HEDIS

Resources

Trainings

• Advanced Medical Home (AMH) Quality Measures Training (PDF)
• Accessing Quality Data via the Secure Provider Portal (PDF)
• Pay for Performance Provider Education (PDF)
• From NC AHEC: 2023 CPT Coding Update: Changes for Evaluation and Management that Providers Need to Know

Tip Sheets

Closing Care Gaps

• Closing Care Gaps Guide (PDF)
• Supplemental Data System (SuDS) Provider Guidance (PDF)
• Supplemental Data System (SuDS) Submission Process (PDF)

HEDIS® Guides

• HEDIS® quick reference guide (HQRG)(Measurement Year 2024) (PDF)
• Adult measures pocket guide (MY2024) (PDF)
• Pediatric measures pocket guide (MY2024) (PDF)

Quality Measures:

• Appropriate Testing for Pharyngitis (CWP) (PDF)
• Cervical Cancer Screening (CCS) Tip Sheet (PDF)
• Childhood Immunizations Status (CIS) (PDF)
• Child and Adolescent Well-Care Visits (WCV) (PDF)
• Chlamydia Screening in Women (CHL) (PDF)
• Comprehensive Diabetes Care (CDC) (PDF)
• Controlling Blood Pressure (CBP) (PDF)
• Eye Exam for Patients with Diabetes (EED) (PDF)
• Follow-Up After Hospitalization for Mental Illness (FUH) (PDF)
  • Additional FUH resources: 
    • Discharge Planner Checklist (PDF)
    • Telehealth Tip Sheet (PDF),
    • Teladoc Signup (PDF)
• Immunization for Adolescents (IMA) (PDF)
• International Normalizing Ratio Monitoring for Individuals on Warfarin (INR) (PDF)
• Kidney Health Evaluation for Patients with Diabetes (KED) (PDF)
• Proportion of Days Covered: Diabetes All Class (PDC-DR) (PDF)
• Timeliness of Prenatal & Postpartum Care (PPC) (PDF)
• Use of Imaging Studies for Low Back Pain (LBP) (PDF)
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) (PDF)
  • Additional WCC resource: Preventive Health Counseling and Education for Children and Adolescents (PDF)

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.

HEDIS and HIPAA

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).