Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) that allows purchasers and consumers to compare quality among health plans.

Regulators also use HEDIS results to evaluate and reward plan performance in various programs such as the Medicare Star Ratings. We are required to report HEDIS values annually on our commercial and Medicare members, making HEDIS a key component of our Quality Program.

Medical and pharmacy claims are the primary administrative data sources for HEDIS and Medicare Star Rating measures. Audit-approved "supplemental" data, such as state immunization registries, laboratory results, vision vendor services and specific electronic medical record (EMR) services, are also used.

NCQA-designated measures rely in part or whole on the addition of medical record data, in combination with administrative data, to achieve valid rates.

NCQA requires a statistically valid sample from all members eligible for these measures.  If any of your patients are a part of that sample and their claims do not reflect compliance with the measure, we will need to review their records. We will work with you to complete these necessary reviews.

Provider tips for improving HEDIS scores:

  • Provide clinically appropriate preventive screenings, tests and vaccines at established recommended intervals.
  • Monitor chronic conditions according to established disease-specific guidelines.
  • Accurate and timely submission of claims will reduce the number of medical record reviews required for HEDIS rate calculation.
  • Ensure that medical record documentation accurately reflects services billed.
  • Submit claims for all services delivered. Submit all applicable diagnostic, procedure, and CPT level II codes (whenever possible). If services are not billed or are billed inaccurately, they are not included in the HEDIS scores.

Frequently asked questions about the 2018 chart review:

What HEDIS measures will be included in the 2018 review?

We are reviewing 11 measures this year:

  • Cervical cancer screening (CCS)
  • Colorectal cancer screening (COL)
  • Prenatal and postpartum care (PPC)
  • Childhood immunization status (CIS)
  • Comprehensive diabetic care (CDC)
  • Controlling high blood pressure (CBP)
  • Medication reconciliation post discharge (MRP)
  • Adult body mass index (BMI) assessment (ABA)
  • Weight assessment and counseling for nutrition and physical activity for children/adolescents (WCC)
  • Immunization for adolescents (IMA) - includes human papillomavirus vaccine (HPV)
  • Transitions of care (TRC)

What dates of service are included in the review?

Office medical records are being reviewed for services received in the 2018 calendar year. However, some measures require additional periods of time, especially for exclusions. The specific periods of service for each member will be included with the chart request.

What types of services and information in the medical record will be reviewed?

The types of services reviewed are specific to each HEDIS measure; however, in general, they include:

  • History
  • Lab results
  • Problem list
  • Specialist consultations
  • Chart notes for a specified period

Are we required to participate?

Yes, your provider agreement requires that you participate in quality improvement activities, such as HEDIS. You must provide access to members' records for these purposes at no cost and without requiring a signed release.

What do I need to do?

We have contracted with Change Healthcare and Ciox Health to contact providers to schedule record retrieval and perform the record review. Retrieval can be done by secure online upload, on-site (for larger clinics), fax or mail. Instructions for submitting the requested records will be included with the chart request.  We are also taking steps to work directly with third-party copy services.

Will I be asked to change or resubmit claims?


Will Change Healthcare and Ciox Health protect members' personal health information?

Yes, they will follow Health Insurance ortability and Accountability Act (HIPAA) guidelines [45 CFR 164.506(c) (4)] while collecting and coding member information, in accordance with our signed business associate agreement. We are not reviewing patient history prior to enrollment with us unless contraindications occurred in the past and would impact the HEDIS rate.

What can I do to minimize the impact to our office?

Change Healthcare, Ciox Health and our staff will work with your office to identify the most efficient way to obtain the necessary chart information. We recognize that each office is unique and that this review can be time-consuming.

Who do I call if I have additional questions?

If you have questions about scheduling or your specific charts, contact Change Healthcare and Ciox Health directly at the phone or fax number included with the request you received. If you have additional questions, please contact Brenda Taylor or Russell Kite:

Brenda: (208) 798-2042 or by email.

Russ: (208) 333-7830 or by email.