HEDIS Measure Specifications
|HEDIS Measure||Required Documentation||Provider Specialty||Exclusions|
Complete immunizations on or before child's 2nd birthday: Combo 3 -
Document the first Hep B vaccine given a the hospital or at birth when applicable, or if unavailable name of hospital where child was born.
|No provider requirements specified||Exclusion: Document all seropositive and illness history of chicken pox, measles, mumps and rubella. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978|
|Well Child Visits: Members age 3 - 6 years||One Well Child Visit with a PCPC during the measurement year.
All three components of a Well Child Visit must be included:
|Controlling High Blood Pressure: Members age 18 - 85 years||Documentation of the most recent blood pressure (BP) reading during the measurement year after the diagnosis of hypertension was made.
Documentation of diagnosis with hypertension (HTN) prior to June 30th of measurement year and evidence of adequately controlled BP (<140/90) during the measurement year.
|No provider requirements specified|
|Diabetic Care - HbA1c Test: Members age 18-75 years with a diagnosis of diabetes||A copy of HbA1c test result from the measurement year or a note from the
medical record indicating the date when the HbA1c test was performed and the test results.
|No provider requirements specified||Exclusions: Members that are not diabetic per current PCP documentation OR members with a diagnosis of polycystic ovaries, gestational diabetes, or steroid induced diabetes. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978|
|Cervical CancerScreening: Women ages 21-64 years||
The lab result or a note from the medical record indicating the date when the cervical cytology was performed and the result or finding.Women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
The following does not qualify:
|No provider requirements specified||Exclusions :Documentation of Total Hysterectomy. Partial Hysterectomy can only be used if absence of cervix is documented. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978|
|Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Members age 3-17 years||Documentation of an outpatient visit with evidence of the following during the measurement year:
||No provider requirements specified
||Exclusions: Members with a diagnosis of pregnancy during the measurement year or year prior. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978|
|Adolescent Immunizations: Members who turn 13 years of age during measurement year||One dose of meningococcal vaccine and one Tdap/Td. Documentation from the medical record indicating the name of the specific antigen and the date of the immunization or a certificate of immunization prepared by an authorized health care provider or agency, including the specific dates and types of immunizations administered.||No provider requirements specified||Exclusion: Anaphylactic reaction to the vaccine or its components. Please fax exclusion documentation to the QI HEDIS department: 1-877-278-9978|
|Diabetic Care - Eye Exam: Members age 18-75 years with a diagnosis of diabetes||An eye screening for diabetic retinal disease.. This includes diabetics who had one of the following:
||Optometrist or Ophthalmologist|
|Diabetic Care - Medical Attention to Nephropathy: Members age 18-75 years with a diagnosis of diabetes||A nephropathy screening test or evidence of nephropathy. This includes diabetics who had one of the following during the measurement year:
||No provider requirements specified|
|Children and Adolescents Access to Primary Care: Members 12 months–19 years of age||
Claim/encounter submission for PCP visit during the measurement year.
|Annual Monitoring for Patients on Persistent MedicationsMembers 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent in the measurement year.||
||No provider requirements specified||Exclusions: Members who had an inpatient (acute or non-acute) claim/encounter during the measurement year|