HEDIS

HEDIS® (Healthcare Effectiveness Data and Information Set) is a widely used set of performance measures developed by the National Committee for Quality Assurance (NCQA®). The information gathered during HEDIS® reviews is used to compare the performance of managed care plans nationally. 

Each spring, The Health Plan QI department nurses review physician office records and complete a set of audited HEDIS reports on preventive services such as immunizations, cancer screening, and prenatal/postpartum care. In addition, we also record the effectiveness of care for members with hypertension and diabetes.

 The “Controlling High Blood Pressure (CBP)” review consists of confirmation of a hypertension diagnosis on a dated problem list or office note, and the subsequent visits to ensure adequate blood pressure control (<140/90).  

Diabetic charts are reviewed for an HBA1c, lipid screening and micro/macro-albumin as well as for blood pressure control and retinopathy screening.

For the diabetes measure, Category II codes may be used for LDL (3048F,3049F, 3050F),nephropathy (3060F,3061F), HbA1c (3044F,3045F,3046F,3047F), and eye exams (2022F,2024F,2026F and 3072F). Use of these codes may decrease the number of charts that we have to request in the future.

For more information on Category II codes as well as other areas that are surveyed administratively, refer to the HEDIS® Coding Guide  and the HEDIS® Overview. 

While most of our HEDIS® rates remain in the higher percentiles when compared with managed care plans nationally, we are always trying to identify ways to improve. We appreciate you accommodating our staff in this process and for continuing to provide quality of care to our members.