HEDIS Requirements
This type of encounter starts the clock for FUA.
What is an Emergency Department visit?
What do we have 34 total of in the framework?
What is golden standard rewards.
Three of these can happen in one year for a member.
What is a pregnancy.
What can be earned one time per year with a code under Mammography?
What is Breast Cancer Screening (BCS-E) reward.
I am set to be the most consistent part of the new framework.
What is System Name.
This system rule ensures only one qualifying dental visit is needed to close the gap.
What is minimum visit requirements (or Frequency Rules)?
How many total Ambetter programs are active on the new framework as of 1/1/2026?
What is 43.
This phrase describes what happens when a follow-up visit occurs on day 31.
What is “so close, but non-compliant”?
This measure requires six separate compliant encounters before 15 months of age.
What is Infant Well Visit (W30 0–15 months)?
I am the most misunderstood denominator rule as I am often interpreted in several different ways.
What is Age Restrictions?
True or false: Gender restrictions are typically part of NCQA defined HEDIS requirements.
What is True.
Total number of Substance Use related rewards that have been standardized.
What is 4 (four) - FUA, FUI, IET-Initial, IET-Engagement.
This single life event can trigger two compliance requirements under the same HEDIS measure.
What is a delivery (Prenatal and Postpartum Care – PPC)?
This pediatric screening must occur before a member turns two — meaning even one day late doesn’t count.
What is Lead Screening (LSC)?
These are used by the HEDIS Data Engine team to determine if someone has qualified for a care gap.
What are Value Set Names.
For PPC, if delivery date logic is incorrect in the system, this downstream impact occurs.
What is incorrect postpartum window calculation?
How many Non-HEDIS rewards have been standardized in the framework?
What is 11.
This basic demographic field can break nearly every measure if it’s wrong.
What is date of birth?
I can be earned between 18-75 years of age once a year but only if I have a specific blood related diagnosis.
What is Diabetes-Blood Pressure (BPD)
I am the one thing that all health plans must define.
What is Reward Amount?
What rewards have two qualifying periods within the same HEDIS measure?
What are Infant Well Visit (W30) and Prenatal and Postpartum Care (PPC).
How many scenarios exist in the numerator for IET-Initial?
What is 15.
This is the most important field across all BH/SUD follow-up measures — and the most dangerous if mapped incorrectly.
What is the index event date (ED visit, discharge, or diagnosis date)?
This reward requires that the medical visit must occur with a PCP or an OB/GYN practitioner, but the practitioner does not have to be the practitioner assigned to the member.
What is the Child/Adolescent Well Visit (WCV)
I am mostly the same for over 85% of the standard rewards.
What is Claim Limitations?