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HEDIS (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, NCQA holds PA Health & Wellness accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) 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. These rates then serve as a basis for physician profiling and incentive programs.

Calculating HEDIS Rates
A few HEDIS measures can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Administrative only measures calculated using administrative data include: annual mammogram, annual Chlamydia screening, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, antidepressant medication management, annual dental care, access to PCP 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 participant 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 requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, annual PAP test, prenatal care, and well-child care.

As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations (HEDIS chart review) is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the participant/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.