HEDIS^® Overview

The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a standardized set of key performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed care plans.

A key feature of HEDIS is that the methodology to collect the data and calculate the measures is standardized in order to permit consumers, government agencies, employers and health plans themselves to more accurately evaluate and trend plan performance and to make comparisons among plans.

The standards specify diagnosis and procedure codes to be included in each measure, selection of member subgroups to be included, criteria for determining pass/fail status, methods of statistical computation, etc. It is essential that all plans submitting HEDIS reports adhere to these established standards so that comparisons among plans are fair and reliable.

To give purchasers and consumers confidence in the accuracy of a health care organization's HEDIS data, NCQA has developed the NCQA HEDIS Compliance Audit™. The audit focuses on two areas, specifically:

(1) an overall information systems capabilities assessment, and
(2) an evaluation of the health plan's ability to comply with HEDIS specifications for individual measures.

The audit analyzes the activities and procedures used by health care organizations when producing HEDIS results. Specific areas addressed by the audit process include:

• information practices and control procedures,
• sampling methods and procedures,
• data integrity,
• analytic file production,
• algorithmic compliance with measurement specifications, and
• reporting and documentation.

The audit format is also used by many states as the standard guideline in evaluating a health plan's reporting capability and accuracy in completing the report.