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Healthcare effectiveness data and information set (HEDIS)

HEDIS is a set of measures created by the National Committee for Quality Assurance (NCQA) that allows comparison across health plans. NCQA uses HEDIS to hold Arkansas Total Care accountable for the timeliness and quality of the healthcare services it provides to members.

Use of HEDIS Scores

HEDIS scores have become more important to health plan providers as State and Federal governments move toward quality-driven healthcare. State healthcare purchasers use HEDIS to assess how effective a health plan’s Preventive Outreach Efforts are. HEDIS scores are used as proof of preventive care from primary care practices. These scores serve as a basis for Physician Profiling and Incentive programs.

Calculating HEDIS Rates

HEDIS rates are calculated by either administrative data or hybrid data. Administrative data consists of claims or encounter data that is sent to the health plan. Measures calculated using administrative data include annual screenings, treatments, medication management, and access to PCP and mental health services. Hybrid data consists of both administrative data and medical record data. Hybrid data requires review of a random sample of member medical records to find data for services that were not reported to the health plan through claims or encounter data. Correct and timely claims or encounter data lowers the need for medical record review. Measures requiring medical record review include comprehensive diabetes care, high blood pressure control, immunizations, prenatal care, and well-child care.


Protected health information (PHI) that is used or disclosed for treatment, payment, or healthcare operations is allowed 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.