HEDIS

Healthcare Effectiveness Data and Information Set (HEDIS) is a performance measurement tool developed and administered by the National Committee for Quality Assurance (NCQA). Health plans across the United States utilize HEDIS to measure the effectiveness, availability and experience of care observed within a health care system.

The California Department of Health Care Services (DHCS) requires that the Alliance perform an annual compliance audit that conforms with a subset of HEDIS measures, referred to as the Managed Care Accountability Sets (MCAS). In addition, the MCAS includes performance measures developed by the Centers for Medicare & Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) also requires that the Alliance audit and submit data for HEDIS measures. Performance on HEDIS measures is used to determine Medicare Advantage Star Ratings. Visit the Stars Ratings page for more information.

Audit Purpose and Timeline

HEDIS audits assess how well the Alliance network of providers is delivering services to its patients. In addition, the audit subjects specific health care data elements to integrity checks, tests of completeness, transparency of reporting, compliance checks, and verification of services.

The audit period runs from January through June and measures care that was delivered in the prior calendar year. In other words, DHCS’ and CMS’ current audit year will assess compliance results from the previous service year. The audit uses the term “Measurement Year” (MY) to refer to the year in which services were delivered.

Data Collection

HEDIS has two forms of data collection, Administrative and Hybrid. Administrative data collection is an automated, behind the scenes process of aggregating all electronic forms of data captured by the Alliance from multiple data sources. In instances where administrative data is not available, hybrid collection methods are used which captures compliance from medical records that are requested from providers.

During the scope of audit, providers are required to participate in the submission of medical records to support hybrid collection when requested by the Alliance and its partnered retrieval vendor. Providers should submit requested documentation within five days of any requests that are made.

Protected Health Information

Under the Health Insurance Portability and Accountability Act, data collection for HEDIS is permitted and health plan requests for medical records do not require additional patient consent or authorization. Alliance members’ PHI is maintained in accordance with all state and federal laws. Data is reported at an aggregate level without individual identifiers.

Results

DHCS audit results are available every fall of the reporting year. The Alliance also reviews annual provider-level outcomes to assess areas where possible improvements can be made across its service network. From this assessment, Alliance Provider HEDIS awards are determined annually.

Performance on the HEDIS measures for the Alliance’s TotalCare (HMO D-SNP) Medicare population are included in the Star Ratings results. Results are released in October of each year.

HEDIS Resources

Provider Portal

• The Alliance’s Provider Portal offers reports that utilize data from provider claims, laboratory, immunization registries and pharmacy, in addition to other data submitted to the portal for relevant Medi-Cal Care-Based Incentive (CBI) and HEDIS measures. These reports are available to assist providers in monitoring patients that may be due for preventative services. Note: Data on the Provider Portal is subject to claims lag.
• The Alliance’s Data Submission Tool on the Provider Portal allows providers to upload data files to increase compliance in Medi-Cal CBI and HEDIS measures. Please see the Data Submission Tool Guide on the Provider Portal for a list of data that is accepted, along with step-by-step instructions on how to submit your data.

HEDIS Code Set

HEDIS FAQ Guide