HEDIS Resource

What is HEDIS?

Healthcare Effectiveness Data and Information Set (HEDIS) is a tool developed in 1991 by the National Committee for Quality Assurance (NCQA).  It is a tool used by more than 90 percent of American’s health plans to measure performance on important dimensions of care and services.  HEDIS reporting by the Health Plan is mandated by NCQA for compliance and accreditation. HEDIS data are collected through a combination of surveys, medical chart reviews and claims/encounter data.  HEDIS consists of 94 measures across 7 domains of care.

Preferred IPA is dedicated to improving quality of care to our members.  We are pleased to share with our provider partners the best practices and reference guide to help provider practice to improve in quality performance in HEDIS.  Our goal is to ensure each of our members receive important necessary preventive screenings/Immunizations based on the HEDIS standards.

Improving HEDIS Performance for Provider Offices:

  • Medicare: Proactively engage members for their Annual Wellness Exam (AWE) and train the Medical Assistant (MA) or office staff to complete the AWE visit form while the member is waiting to be seen by NP/PA/MD.  The MA can complete almost 80% – 90% percent of the AWE form. NP/PA/MD to review form elements with members.
  • Medi-Cal: Complete all the Preventive Screening for adults (e.g., Breast, Cervical and Colorectal Cancer Screening, Diabetes Care, etc.) and Annual Well-Child Visits.  Ensure the Childhood Immunizations are completed timely and submit the data to the IPA and into the California Immunization Registry (CAIR) (e.g., Childhood Immunization – Combo 3:  Ensure members complete at least 7 antigen series before their 2nd birthday and ideal if completed within first 12 months).
  • Recommended for all members: Provide future office visit date and time via an appointment card and conduct curtesy phone call reminder to members 1-3 days before the visit (especially Senior Members).
  • Medical Record and Claims/Encounter: Submit accurate coded claims/encounter data for each service rendered and keep accurate, legible and complete patient medical record (ensure to sign/EMR stamp the medical record/chart). Claims/Encounter Timeliness: Submit encounter/claims to Preferred IPA and/or Health Plan within 30 days from Date-of-Service (DOS).  Educate your biller on all the HEDIS requirements and codes needed for various HEDIS measures.  Please reach out to your Preferred IPA Provider Representative if you would like Preferred IPA subject matter experts to conduct training/education.  Please send/fax medical records to the Health Plans/IPA within 5 working days or earlier when requested.

HEDIS Measures and Coding Best Practice

Health Plan HEDIS Resources