HEDIS/ECDS
A tool used by health plans to measure performance of care and services delivered to members
What is HEDIS or Healthcare Effectiveness Data and Information Set?
NCQA is the acronym for this accrediting body.
What is National Committee for Quality Assurance?
A mutual agreement between PHP and another credentialing organization that eases the way of practitioners and organizational providers by leveraging an approved organization’s credentialing decision.
What is credentialing delegation agreement?
The Quality Ratings Programs use this to monitor clinical outcomes, member experience, and health plan processes. Types include HEDIS, Medicare Stars, CAHPS, and CCO Incentive.
What are Quality Measures?
This team works on a project every year from January – May and team members review charts to ensure measures are met and that we pass audit.
Who is the HEDIS Team?
Electronic Clinical Data Systems (ECDS) reporting is the path to digital measure reporting. Digital measure reporting means moving to standards-based technology that makes quality operations simpler and more efficient. More importantly, it is about more relevant measures and the increased use of clinical data to enable better measurement, better care and new payment models.
What is ECDS?
This type of requirement is so important that non-compliance can cause an organization to fail your entire survey.
What is must-pass?
Verification process conducted to ensure that Members are receiving quality cared from quality practitioners with the appropriate training, experience who are continually monitored for potential quality issues such as CMS exclusions, licensing limitations or malpractice claims or settlements
What is Credentialing process?
The quality team uses this to ensure the Quality Ratings Programs are effective, and regulatory requirements and the needs of members are being met.
What are Evaluations?
This team works with regulatory on provider complaints.
Who is Patient Safety?
Use of administrative data (e.g., claims), supplemental data (e.g., EMR, care management data), and medical record data
How do we capture HEDIS data?
PHP has been accredited for this many years
What is 10 years?
This team of nurses works to review quality of care concerns and member complaints received about contracted practitioners.
What is Patient Safety Team?
Providers participate in this program to receive payment for their performance on quality measures or participation in quality initiatives.
What are Quality Incentive Programs?
This team facilitates an onsite audit
Who is the NCQA team?
Electronic Health Records, Health Information Exchanges (HIE) and Clinical Registries, Case Management Systems, Administrative (Claims)
What are the four ECDS data categories?
In Health Equity Accreditation, a work plan and program description is required for this
What is CLAS (Culturally Linguistically Appropriate Services)?
Evaluation process of practitioners or organizational providers at least every 3 years.
What is recredentialing process?
These are programs overseen by the quality team: Stars, CCO Incentive, Quality Ratings System, and NCQA Health Plan Ratings.
What are Quality Ratings Programs?
This team works with the HEDIS team on pulling data and reports.
Who is the Clinical Analytics team?
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC); Childhood Immunization Status (CIS); Immunizations for Adolescents (IMA); Cervical Cancer Screening (CCS); Care for Older Adults (COA); Controlling High Blood Pressure (CBP); Diabetes; Transitions of Care (TRC); Prenatal and Postpartum Care (PPC)
What are the measures reviewed during the HEDIS hybrid review?
Also called a “barrier,” these must be identified to improve performance.
What is root cause?
Commonly known as facilities.
What are organizational providers?
The Quality Ratings team implements these to improve performance on or meet the requirements of quality measures.
What are Quality Improvement Initiatives?
This team works closely with the network team to ensure providers meet minimum criteria for contracting.
Who is credentialing?