HEDIS FAQ Guide

Healthcare Effectiveness Data and Information Set (HEDIS) is a performance measurement tool developed and administered by the National Committee for Quality Assurance (NCQA). The California Department of Health Care Services (DHCS) uses HEDIS to monitor the performance of Medi-Cal managed care plans and the Centers of Medicare and Medicaid Services (CMS) uses HEDIS in Star Ratings for measuring quality of Medicare Advantage plans.

• The Alliance performs an annual compliance audit that conforms with a subset of HEDIS measures, referred to as the Managed Care Accountability Sets (MCAS). The MCAS includes performance measures developed by the Centers for Medicare & Medicaid Services (CMS) and NCQA.
• The Alliance also performs an annual audit on a subset of HEDIS measures for TotalCare (HMO D-SNP), the Alliance’s Medicare Advantage plan. The data from these audited measures is used to calculate the Alliance’s overall Star Rating for TotalCare.
• All Medi-Cal and Medicare Advantage plans undergo annual, retrospective HEDIS reviews to monitor specific domains of care.
• Results are used to measure performance, identify quality initiatives, and provide educational programs for providers and members.

Providers play a central role in promoting the health of Alliance members. Providers and office staff can help support the HEDIS process by:

• Providing appropriate care within designated time frames.
• Documenting all care in the patient’s medical record.
• Accurately coding all claims and billing the Alliance in a timely manner.

No. Under the Health Information Portability and Accountability Act (HIPAA), 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.

• Administrative data obtained from the Alliance’s claims system.
• Laboratory data.
• Data submitted via the Alliance’s Data Submission Tool on the Provider Portal.
• Immunization Registry data.
• Chart data obtained from medical record review.

The Alliance’s HEDIS medical record collection and abstraction vendor, KDJ, will contact providers directly to request medical records for select members.

• Data collection methods include fax, mail, on-site visits, and remote electronic medical record (EMR)
  system access.
• Providers should submit requested documentation within five days of medical record request.

Medical record requests will begin as early as February and end by mid-May.

No. Each request will include a list of members, the measure(s) selected for review and the relevant portions of medical records that are needed.

When the record requests are sent, contact instructions will be listed on the request.

No. HEDIS measurement year (MY) 2024 can look back as many as ten years for some measures.

More information can be found at www.ncqa.org.

Per your Alliance contract, we do not reimburse for medical record copies/materials requested for HEDIS data collection.

Please direct any HEDIS questions to [email protected].