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 Nebraska Total Care accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership. Annually, Nebraska Total Care's HEDIS® scores can be found in the Quality Improvement Evaluation posted to this website.
Use of HEDIS® Scores
As both state and federal governments move toward a healthcare industry that is driven by quality, HEDIS® rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS® rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician specific scores are being used as evidence of preventive care from primary care office practices. These rates 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 PCP 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® Quick Reference Guide 2023 (PDF)
HEDIS® and 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 does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate agreement.
Collecting HEDIS® Information from Providers
Nebraska Total Care is accredited by National Committee for Quality Assurance (NCQA). The NCQA accreditation process requires collection of Healthcare Effectiveness Data and Information Set (HEDIS®) annually, as does the Heritage Health contract with Nebraska Total Care. The HEDIS® data collection begins early in the calendar year and all collections are submitted to the national HEDIS® organization in May.
HEDIS® Quick Reference Guide
Nebraska Total Care strives to provide quality healthcare to our membership as measured through HEDIS® quality metrics. We created the HEDIS® Quick Reference Guide 2023 (PDF) to help you increase your practice’s HEDIS® Rate. Please always follow the State and/or CMS billing guidance and ensure the HEDIS® codes are covered prior to submission.