HEDIS

  • The Healthcare Effectiveness Data and Information Set (HEDIS) is a set of nationally recognized performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS is used by more than 90 percent of U.S. health plans to measure quality of care, access to care, and satisfaction with care.

    Thoroughly documenting and coding patient screenings helps us assess quality care for HEDIS measurements and establish appropriate programs for patients with specific health conditions. And, the more accurately claims are coded, the fewer medical record reviews are needed for HEDIS measurement.

    HEDIS Measures

    Our quick reference coding guide ensures you're sending complete claims and are paid for all the services you provide.

    For more information about HEDIS, visit ncqa.org.

  • Follow-up Care for Children Prescribed with ADHD Medications

    Measure

    Children 6 to 12 years of age with newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication that have at least three follow-up care visits within a 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed.

    Antidepressant Medication Management

    Measure

    Patients 18 years of age and older who were treated with antidepressants, had a diagnosis of major depression, and who remained on an antidepressant medication treatment for at least 6 months.

    Two rates are reported:

    1. Effective Acute Phase Treatment: Patients who remained on antidepressant medication for at least 84 days (12 weeks)
    2. Effective Continuation Phase Treatment: Patients who remained on antidepressant medication for at least 180 days (6 months)

    Mental Illness Follow-Up After Hospitalization

    Measure

    Patients six years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner. Two rates are reported:

    1. The percentage of patients who received follow-up within 30 days of discharge
    2. The percentage of patients who received follow-up within seven days of discharge

    Measure

    This measure is the percentage of patients 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled during the measurement year, based on the following criteria:

    • Patients 18 to 59 years of age whose BP was less than 140/90 mm Hg
    • Patients 60 to 85 years of age with a diagnosis of diabetes whose BP was less than 140/90 mm Hg
    • Patients 60 to 85 years of age without a diagnosis of diabetes whose BP was less than 150/90 mm Hg1

    Source:

    1US Department of Health and Human Services. , National Institutes of Health., National Heart, Lung, and Blood Institute., National High blood Pressure Education Program., "National High Blood Pressure Education Program" NIH Publication No. 03-5233 December 2003 Accessed March 31, 2015

    Comprehensive Diabetic Care

    Measure

    Patients 18-75 years of age who received care for diabetes (Types 1 and 2) and had each of the following:

    • Hemoglobin A1C (HbA1c) testing
    • Eye exam (retinal) performed
    • Medical attention for nephropathy
    • Blood pressure control (<140/90mm Hg) for type 1 and 2

    Adult BMI

    Measure

    Patients 18-74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

    View the Adult BMI HEDIS tip sheet.

    Adult Flu Vaccination

    Measure

    Patients 18-64 years of age who have received the influenza vaccine during the measurement year.

    Breast Cancer Screenings

    Measure

    Women 50-74 years of age who had a mammogram to screen for breast cancer.

    Cervical Cancer Screenings

    Measure: Proposed

    Women 21-64 years of age who were screened with cytology within the past three years and women ages 30-64 who were screened with cytology/HPV co-testing within the past five years.

    Children/Adolescent Weight Assessment and Counseling

    Measure

    Patients 3-17 years of age who had one or more outpatient visits with PCPs or OB/GYN and documented evidence of all the following during the measurement year:

    • Body mass index (BMI) percentile
    • Counseling for nutrition
    • Counseling for physical activity

    Childhood Immunizations

    Measure

    Children two years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and 10 separate combination rates.

    Chlamydia Screening

    Measure

    Women ages 16-24 identified as presumed sexually active and have had at least one test for chlamydia during the measurement year.

    Colorectal Cancer Screening

    Measure

    Patients 50-75 years of age who had one of the following screenings for colorectal cancer.

    Appropriate screenings are defined by one of the following:

    • FOBT (fecal occult blood test) or FIT (fecal immunochemical test) during the measurement year
    • FIT-DNA test during the measurement year or the two years prior to the measurement year
    • Flexible sigmoidoscopy during measurement year or the four years prior to the measurement year
    • CT colonography during the measurement year or the four years prior to the measurement year
    • Colonoscopy during the measurement year or the nine years prior to the measurement year

    Immunizations for Adolescents (both male and female)

    (The HPV Vaccine for Female Adolescents was retired as its own measure and added to this measure since it's now applicable for both male and female adolescents.)

    • Meningococcal MC (between 11th and 13th birthday)
    • Tdap or TD (between 10th and 13th birthday)
    • 3 doses of the humanpapillomavirus (HPV) vaccine by their 13th birthday

    Prenatal and Postpartum Care

    Measure

    Women who delivered a live birth and experienced:

    • Timeliness of prenatal care: had a prenatal care visit with an obstetrician, gynecologist, midwife, family practitioner, or other primary care provider (PCP) in the first trimester of pregnancy or within 42 days of enrollment
    • Postpartum care: had a postpartum visit with an obstetrician, gynecologist, midwife, family practitioner, or other PCP on or between 21 and 56 days after delivery2

    2Peter Bach et al. HEDIS 2015 Technical Specifications for Health Plans (National Committee for Quality Assurance 2014), 243-250.

    Avoidance of antibiotics treatment in adults with acute bronchitis

    Measure

    Adults 18-64 years of age with a diagnosis of acute bronchitis who were not given an antibiotics prescription.

    Child Pharyngitis

    Measure

    Patients 2-18 years of age who were diagnosed with pharyngitis, tonsillitis, or streptococcal sore throats who were dispensed antibiotics and received group A streptococcus (strep) tests during office or emergency room visits.

    Children with URIs

    Measure

    Children ages 3 months to 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.

  • Premera Patient Support Programs

  • The Alere™™ Maternity Program provides education and support services to all eligible pregnant members and case management services for those eligible members identified as high-risk. The Newborn Program provides case management on site or by phone, and assists facility staff in providing discharge planning, support, and resources for parents. It also includes concurrent review for neonatal intensive care unit (NICU) services. Be sure to call customer service to check Alere benefits for Premera members who are high-risk maternity patients or for newborns in the neonatal intensive care unit (NICU). If the member qualifies, you can refer a patient by calling Alere at 855-314-2229, Monday through Friday, 5:30 a.m. to 6:00 p.m. PST.
    This voluntary service is offered to participants with health complexity, high utilization, and functional impairment. Health complexity encompasses multiple diagnoses, physical and mental health co-morbidities, personal, social, and financial upheaval, and health system issues. Premera’s Integrated Case Management team works cooperatively with members and providers to identify and overcome clinical and non-clinical barriers to improve health outcomes. Providers can refer eligible Premera members by calling 888-742-1479, Monday through Friday, 6 a.m. to 8 p.m. and Saturdays 10 a.m. to 2 p.m., or emailing case.management@premera.com.
    Transition management is for members who need support during transition from home to hospital and hospital to home. Providers can refer eligible Premera members by calling 888-742-1479, Monday through Friday, 6 a.m. to 8 p.m. and Saturdays 10 a.m. to 2 p.m., or emailing case.management@premera.com 
    Personal health support is available to eligible health plan members with one of the following five chronic conditions: Diabetes, Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease (COPD), and Asthma. Providers can refer eligible Premera members for personal health support by calling 800-722-4714, option 6, Monday through Friday, 6 a.m. to 8 p.m. and Saturdays 10 a.m. to 2 p.m., or emailing PersonalHealthSupportCoach@Premera.com.