HEDIS® stands for Healthcare Effectiveness Data and Information Set, and is a tool developed by the National Committee for Quality Assurance (NCQA) to measure health plan performance on important dimensions of care and service. HEDIS® is an annual project of data collection and assessment of defined performance measures; results are used to evaluate where to focus quality improvement efforts.
Annual HEDIS® data is collected from Connecticut Medical Assistance Program (CMAP) providers by CHNCT which later undergoes a compliance audit conducted by an NCQA certified HEDIS® auditor. HEDIS® data affords a unique opportunity to assess the care provided to the entire Connecticut Medicaid/CHIP membership.
Medical records are reviewed for services performed in the previous calendar year; however, some measures may require additional periods of time, especially for exclusions. For example, the measurement period for breast cancer screening is within the previous two years; however, if a member had a prior bilateral mastectomy, CHNCT would require documentation of the earlier procedure to exclude this member from the screening data for the year under review. The specific periods of service for each member are included within the medical record request issued to practices by CHNCT.
The types of services reviewed are specific to each HEDIS® measure, but generally include:
|HEDIS® Measure||Medical Record(s) Required|
|Diabetic Member Comprehensive Diabetes Care (CDC)||Retinal eye exam
HbA1c test and result
Blood pressure reading
|Pediatric Member Lead Screening in Children (LSC)||Date of lead screening test with result/finding|
HEDIS® rates are the most widely used set of health care performance measures on important preventive and clinical services. As a result, HEDIS® is the most widely used evaluation tool to measure provider performance and quality of care.HEDIS® Overview & Introduction
Q: What do CMAP providers need to do in support of the annual HEDIS® medical record review?
A: CHNCT relies on the data collected from CMAP providers to comply with HEDIS®. In February each year, randomly selected providers will receive a medical record review letter outlining the process along with an instruction sheet. Medical record data collection will begin in February and continue into May. The sooner that practices provide requested clinical information, the smoother the process will go. Medical records requested should be faxed to a secure, dedicated fax line; sent via secure email; or mailed via the United States Postal Service. CHNCT can also obtain medical records on-site by request.
If your practice would like CHNCT to obtain medical records on-site or if your practice stores medical records in a central location and would like CHNCT to address all requests for medical records to that location, please let us know right away. You can contact us by email at firstname.lastname@example.org or by phone at 1.866.317.3301 Monday - Friday from 8:00 a.m. to 5:00 p.m.; a voicemail is available after hours.
Q: Who will review the medical records?
A: CHNCT licensed nurses will review the submitted medical records.
Q: Will providers be asked to change or resubmit claims?
Q: Will the member's personal health information be protected?
A: Yes, all CHNCT staff follow the Health Insurance Portability and Accountability Act (HIPAA) guidelines while collecting and reviewing member information.
Content reproduced with permission from HEDIS 2019, Volume 2: Technical Specifications for Health Plans by the National Committee for Quality Assurance (NCQA). HEDIS® is a registered trademark of NCQA. HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or accuracy of any coding contained in the specifications. To purchase copies of this publication, including the full measures and specifications, contact NCQA Customer Support at 888-275-7585 or visit www.ncqa.org/publications.
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