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 Superior HealthPlan accountable for the timeliness and quality of health care services (acute, preventive, mental health, etc.) delivered to its diverse membership.

Use of HEDIS Scores

As both State and Federal governments move toward a health-care industry that is driven by quality, HEDIS rates are becoming more and more important, not only to health plans, but to the individual provider as well. State purchasers of health care use the aggregated HEDIS rates to evaluate the effectiveness of a managed care plan’s ability to demonstrate an improvement in preventive health outreach to its members. Physician-specific scores are being used as evidence of preventive care provided by primary care office practices. These rates can then serve as a basis for physician profiling and incentive programs.

Calculating HEDIS Rates

HEDIS rates can be calculated in two ways: 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 the Health Information Portability and Accountability Act (HIPAA)

As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506), and use or disclosure for these purposes does not require the consent or authorization from the member/patient. For persons other than providers who are participating in HEDIS activities, such as third party vendors and/or medical record review staff, they sign a HIPAA-compliant Business Associate Agreement with Superior HealthPlan prior to accessing any PHI.