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HEDIS Measures & Billing Codes

What is HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) to objectively measure, report, and compare quality across health plans. NCQA develops HEDIS measures through a committee represented by purchasers, consumers, health plans, health care providers, and policy makers.

What Are the Scores Used For?

As state and federal governments move toward a quality-driven healthcare industry, HEDIS rates are becoming more important for both health plans and individual providers. State purchasers of healthcare use aggregated HEDIS rates to evaluate health insurance companies' efforts to improve preventive health outreach for members.

Physician-specific scores are also used to measure your practice's preventive care efforts. Your practice's HEDIS score determines your rates for physician incentive programs that pay you an increased premium — for example Pay For Performance or Quality Bonus Funds.

How Are Rates Calculated?

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the need for medical record review. If services are not billed or not billed accurately, they are not included in the calculation.

How Can I Improve My HEDIS Scores?

  • Submit claim/encounter data for each and every service rendered
  • Make sure that chart documentation reflects all services billed
  • Bill (or report by encounter submission) for all delivered services, regardless of contract status
  • Ensure that all claim/encounter data is submitted in an accurate and timely manner
  • Consider including CPT II codes to provide additional details and reduce medical record requests


As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.

Provider Quality Resources

  • Annual Flu Vaccine (FVA) – Wellcare By Health Net (coming soon)

  • Monitoring Physical Activity (MPA) – Wellcare By Health Net (coming soon)

  • Reducing the Risk of Falling (RRF) – Wellcare By Health Net (coming soon)

Refer to Provider Quality Improvement page for more resources.

Last Updated: 04/18/2024