The Healthcare Effectiveness Data and Information Set (HEDIS)

What is HEDIS?

HEDIS is a widely used set of performance measures in the managed care industry, which is developed and maintained by the National Committee for Quality Assurance (NCQA).

HEDIS is a set of standardized quality measures. This standardization helps the public compare the performance of organizations across the nation. HEDIS measures are also part of Horizon NJ TotalCare (HMO D-SNP)’s contracts with the state, Centers for Medicare and Medicaid Services (CMS) and NCQA accreditation.

HEDIS includes more than 90 measures across six domains of care:

  1. Effectiveness of Care
  2. Access/Availability of Care
  3. Experience of Care
  4. Utilization and Risk Adjusted Utilization
  5. Health Plan Descriptive Information
  6. Measures Collected Using Electronic Data Systems

HEDIS measures focus on prevention, screenings and conditions across all body systems, access to care, satisfaction with care, as well as utilization of specific procedures and care settings. NCQA defines each measure, specifically identifying eligibility and compliance criteria.

What is your role?

Process Requirements

  • HEDIS data collection is a year-round process using claims data as the primary source.
  • Completing accurate coding of all claim submissions from the provider’s office is a priority and will ensure the integrity of the data.
    • - Claim submissions should be timely to avoid delays in monthly updates to tracking reports.
  • NCQA allows plans to collect additional HEDIS data through a hybrid process called Medical Record Review (MRR), which is conducted January through May.
    • - Medical records are collected through fax, Managed File Transfer (MFT) and by a Quality auditor.
    • - Quality auditors go to provider offices to search for information that may exist in the chart that was either never submitted via code on a claim or was submitted but with a non-HEDIS (Value Set) code.
    • - Partnering with Horizon BCBSNJ to allow remote access to your electronic medical record (EMR) system during this time will reduce the administrative burden for your staff and expedite the review process. Contact us at to coordinate.
  • Practices are encouraged to review their gap lists and submit documentation for members who meet criteria for permanent exclusion from a measure, when applicable.