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Healthcare Effectiveness Data & Information Set (HEDIS)

We use HEDIS to measure quality of care for patients and plan member experience.

We continually collect and analyze data to monitor our performance and identify areas for improvement. In collaboration with our network providers, we support effective and affordable screening and treatment practices to prevent health issues and manage chronic conditions.

Martin’s Point, along with nearly every health plan in the US, uses the Healthcare Effectiveness Data and Information Set (HEDIS®) to measure quality of care and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) to measure member experience.

Standard measures of clinical quality and customer experience allow individuals to compare health plans and make informed choices when it comes to selecting a health plan provider for themselves and their family members.

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HEDIS Data Collection Demographics & RES HEDIS Star Measures Helpful Resources


HEDIS Data Collection and Submission

How is HEDIS data collected?

Depending on the measure, data may be collected through:

  • Administrative/claims data
  • Supplemental files sent in by the provider during the year
  • Medical record reviews
  • Measure specifications outline measure description, exclusions and how the data may be collected.
    • If using a third party vendor for medical record retrieval, please specify name of third party vendor to appropriately request records directly.
  • Survey Method
  • Electronic Clinical Data Systems (ECDS)


Data submission documentation requirements

When gathering documentation, be sure to include the following items:


number one icon  Proof of service documentation must include all of the following:
  • Members full name (first and last)
  • Date of birth (DOB)
  • Date of service (DOS)
  • Provider signature

number two icon  Proof-of-service document can be:

  • Screenshot (ex: snippet tool)—Note: Full member demographics must be included in the snippet
  • PDF

number three icon  Format for saving proof-of-service document as:
  • Member’s Last Name, First Name, DOB, Measure Abbreviation
    • Example: Smith, John, 01.01.2001, COL

Important Notes Regarding Data Submission:

  • Only completed events count toward HEDIS compliance.
  • A date must be specific enough to determine a test or service was performed within the time frame specified, not merely ordered (ex: noncompliant terms such as "up to date", "current", etc.).
  • Documentation in a medical record of a diagnosis or procedure code alone does not comply with the numerator criteria.
  • Information on a fax cover sheet and/or handwritten documentation that is NOT generated directly from an EMR or part of the permanent record cannot be used.

Please submit any questions and/or concerns regarding medical record retrieval please reach out to:

[email protected] | Fax Records to: 207-828-7853

 

Language Diversity and Race/Ethnicity (RES) Stratification Requirement 

The data submitted will help to provide insights into disparities in health plan performance variations based on racial and ethnic demographics.

Language Diversity and Race/Ethnicity (RES) Stratification is now required for the following measures:

  • Controlling High Blood Pressure (CBP)
  • Prenatal and Postpartum Care (PPC)
  • Child and Adolescent Well-Care Visits (WCV)
  • Immunization for Adolescents (including IMA-E)
  • Asthma Medication Ratio (AMR)
  • Colorectal Cancer Screening (COL-E)
  • Follow-Up After Emergency Department Visit for Substance Use (FMC)
  • Pharmacotherapy for Opioid Use Disorder (POD)
  • Initiation and Engagement of Substance Use Disorder Treatment (IET)
  • Well-Child Visits in the First 30 Months of Life (W30)
  • Breast Cancer Screening (BCS-E) 
  • Adult Immunization Status (AIS-E)
  • Eye Exam for Patients With Diabetes (EED)
  • Kidney Health Evaluation for Patients With Diabetes (KED)
  • Follow-Up After Hospitalization for Mental Illness (FUH)
  • Follow-Up After Emergency Department Visit for Mental Illness (FUM)
  • Childhood Immunization Status (CIS-E)
  • Cervical Cancer Screening (CCS-E)
  • Prenatal Immunization Status (PRS-E)
  • Prenatal Depression Screening and Follow-Up (PND-E)
  • Postpartum Depression Screening and Follow-Up (PDS-E)
Report one of the nine categories for race:
  • White 
  • Black or African American 
  • American Indian and Alaska Native 
  • Asian     
  • Native Hawaiian and Other Pacific Islander    
  • Some Other Race 
  • Two or More Races      
  • Asked but No Answer 
  • Unknown 
Report one of the four categories for ethnicity:
  • Hispanic/Latino
  • Not Hispanic/Latino
  • Asked but No Answer
  • Unknown

Language Diversity:

  • Preferred Spoken Language
  • Preferred Written Language

2026 HEDIS Star Measures

For the 2026 Star Ratings, the adjusted HEDIS measures for several subject areas can be found here:

Plan All-Cause Readmission (PCR)

Eligible Population

Members 18 years of age as of December 31st of the measurement year.

Enrollment

Member must be enrolled in a medical benefit 365 days prior to the Index Discharge Date through 30 days after the Index Discharge Date.

Definition

Members 18 years of age and older, the number of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of one of the following test(s) or screening(s):  
  DOS (DATE OF SERVICE) WINDOW
Index Hospital Stay (IHS) Index hospital stay. An acute inpatient or observation stay with a discharge on or between January 1 and December 1 of the measurement year, as identified in the denominator.
Index Discharge Date
 The Index Discharge Date must occur on or between January 1 and December 1 of the measurement year.
Index Readmission Stay An acute inpatient or observation stay for any diagnosis with an admission date within 30 days of a previous Index Discharge Date.
Index Readmission Date The admission date associated with the Index Readmission Stay.
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Members in hospice or using hospice services anytime during the measurement year
  • Exclude acute hospitalizations for the following reasons:
    • Member died during inpatient stay
    • Member with a principle diagnosis of pregnancy on the discharge claim
    • Principle diagnosis of a condition originating in the perinatal period on the discharge claim

     

  • Planned admissions for:
    • Chemotherapy maintenance
    • Principle diagnosis of rehabilitation
    • Organ transplant
    • Potentially planned procedure without a principle acute diagnosis

     

  • Exclude the hospital stay if the direct transfer's discharge date occurs after December 1 of the measurement year
  • Exclude hospital stays where the Index Admission Date is teh same as the Index Discharge Date

Breast Cancer Screening (BCS-E)

Eligible Population

Women 52-74 years of age as of December 31 of the measurement year.

Enrollment

October 1 two years prior to the measurement year through December 31 of the measurement year.

Definition

The percentage of women between the ages of 52-74 who have had a mammogram to screen for breast cancer on or between October 1 (to two years prior to the measurement year) and December 31 (measurement year).

Documentation submitted must include ONE of the following:


Martin's Point star icon  Documentation of mammogram performed during the measurement period  
OR 

Martin's Point star icon  Documentation in member’s history noting, “mammogram completed” and date completed  
  • If the full date of service is unknown, using the documented year only is acceptable 
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • NEW: Members who received gender-affirming chest surgery with a diagnosis of gender dysphoria.
  • Documentation of bilateral mastectomy anytime in member’s history through December 31 of the measurement year.
  • Documentation must indicate a mastectomy on both the left and right side on the same or different dates of service
  • Must occur during the measurement year:
    • Hospice or using hospice services
    • Palliative care
    • Deceased
    • Living in Long Term Care
    • Frailty and Advanced Illness 

Not Acceptable Documentation

Do not count MRIs, ultrasounds or biopsies as these are performed adjunct to a mammography and alone are not counted.

Colorectal Cancer Screening (COL-E)

MY2024 Update: COL has been updated to COL-E and is an electronic measure only.

Eligible Population

Members 45-75 years of age as of December 31 of the measurement year.

Enrollment

Member must be enrolled in a medical benefit during the measurement year and year prior to the measurement year.

Definition

Members age 45-75 who have completed screenings for colorectal cancer.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of one of the following test(s) or screening(s):  
TEST TYPE DOS (DATE OF SERVICE) WINDOW
Colonoscopy Measurement Year or nine (9) years prior
Fecal Occult Blood Test (FOBT)
gFOBT (guaiac), FIT/iFOBT (immunochemical)
 Measurement Year
Flexible Sigmoidoscopy Measurement Year or four (4) years prior
Flexible Sigmoidoscopy & Annual FIT Every 10 years with FIT every year 
 CT Colonography  Measurement Year or four (4) years prior
 FIT-DNA (Cologuard)  Measurement Year or two (2) years prior
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Members who had colorectal cancer or a total colectomy any time during history through December 31 of the measurement year.
  • Palliative Care
  • Members in hospice or using hospice services anytime during the measurement year.
  • Members who died any time during the measurement year.
  • Frailty and Advanced Illness
  • Living in Long Term Care

 

COL-E Documentation Information:
  • Documentation must include the type of screening and date when test was performed.
    • If report indicates the type of screening, the date the screening was performed (collected date) and resulted date, use collected date since this is the procedure date.
  • If a pathology report does not indicate the type of screening, or if the procedure report indicates an incomplete exam or poor prep, look for evidence of where scope advanced to:
    • To the Cecum = colonoscopy
    • To the sigmoid colon = flexible sigmoidoscopy
  • If the colonoscopy is documented in the "medical history" section of the medical record, then a result/finding is not required regardless of the setting (i.e., inpatient, outpatient or member reported).
    • A result is not required if documentation includes:
      • Screening type (colonoscopy, flexible sigmoidoscopy, etc.)
      • Date the test was performed, this is considered part of the member's medical history and a result is not required.
  • Colonoscopy indicating “poor bowel prep” or “incomplete exam” must include documentation that the scope advanced to cecum for a colonoscopy or into the sigmoid colon for flexible sigmoidoscopy.
NOTE: Cologuard is a stool DNA with FIT test and is not the same as a FIT test (FOBT immunochemical test) alone.

Not Acceptable Documentation

  • CT scan of the abdomen and pelvis (it is not the same as a CT Colonography and is not acceptable).
  • Documenting terms such as “recent”, “most recent”, “at a prior visit”, or “Colonoscopy up to date” as these are not specific enough to know when an event occurred.
  • Documentation supporting “poor bowel prep” or “incomplete exam” without documentation supporting the scope advanced to the cecum for a completed colonoscopy or sigmoid colon for a flexible sigmoidoscopy.
  • Documentation that does not specifically state the type of screening completed.

Controlling Blood Pressure (CPB)

Eligible Population

Members 18-85 years of age as of December 31 of the measurement year.

Enrollment

Member must be enrolled in a medical benefit during the measurement year.

Definition

Members 18-85 years of age who had a diagnosis of hypertension *(HTN) and whose most recent BP was adequately controlled (systolic less than 140/diastolic less than 90) during the measurement year.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of the following test(s) or screening(s):  
TEST TYPE DOS (DATE OF SERVICE) WINDOW
Blood Pressure 01/01 Measurement Year–12/31 Measurement Year
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • End-stage renal disease (ESRD): dialysis, nephrectomy, or kidney transplant.
  • Palliative Care
  • Members in hospice or using hospice services anytime during the measurement year.
  • Members with a diagnosis of pregnancy
  • Frailty and Advanced Illness
  • Living in Long Term Care
  • Non-acute inpatient admission
    • This includes rehabilitation, nursing home, inpatient mental health, etc.

 

CPB Documentation Information:
  • Documentation must include the BP reading AND date of service.
  • The BP reading MUST occur on or after the date of the second diagnosis of hypertension.
  • If multiple blood pressure readings are listed on the same date of service, use the lowest systolic and the lowest diastolic BP on that date as the representative BP.
  • BP readings taken by the member (with digital device only) and documented in the member's medical records are eligible for use.
  • Include BP readings taken on the same day as member receives a common low-intensity or preventive procedures (ex: vaccinations, injections, TB test, IUD insertion, exe exam with dilating agents, wart or mole removal, etc.).

Not Acceptable Documentation

  • Do not include BP readings taken during the following:
    • Taken during an acute inpatient stay or an ED visit
    • Taken on the same day as a diagnostic test or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure (fasting blood tests are an exception)
    • Taken by the member using a non-digital device such as with a manual blood pressure cuff and a stethoscope
    • An aortic systolic/diastolic non-invasive central blood pressure measurement
    • An incomplete BP reading (systolic or diastolic alone)
    • Ranges and thresholds as they do not meet criteria for this measure:
      • A distinct numeric result for both systolic and diastolic BP reading are required
  • The member is not compliant if:
    • The BP reading is >/= 149/90 mm Hg or is missing
    • There is no BP reading during the measurement year
    • If the reading is incomplete

Glycemic Status Assessment for Patients with Diabetes (GSD): A1C

MY2024 Update: Hemoglobin A1c Control for Patients with Diabetes (HBD) measure was updated to Glycemic Status Assessment (GSD)

Eligible Population

Members 18-75 years of age as of December 31 of the measurement year.

Enrollment

Member must be enrolled in a medical benefit during the measurement year.

Definition

The percentage of members 18-75 years of age with a diagnosis of diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c (HbA1c) or glucose management indicator (GMI)) was at the following levels during the measurement year:

Glycemic Status < 8.0%   |   Glycemic Status > 9.0%

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of the following test(s) or screening(s):  
TEST TYPE DOS (DATE OF SERVICE) WINDOW
HbA1c 01/01 Measurement Year–12/31 Measurement Year
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions: 
  • Palliative Care
  • Members in hospice or using hospice services anytime during the measurement year
  • Members who died any time during the measurement year
  • Frailty and Advanced Illness
  • Living in Long Term Care


COL-E Documentation Information:
  • Documentation in the medical record must include all of the following:
    • Test performed
    • Date glycemic status assessment (HbA1c/GMI) was performed
    • Result
  • The result of the most recent glycemic status assessment (HbA1c or GMI) performed during the measurement year is <8.0% as documented through laboratory data or medical record review
    • If multiple glycemic status assessment were recorded on the same date, report the lowest result.
    • GMI results collected by the member and documented in the member's medical record are eligible for use in reporting.
    • GMI values must include documentation of the continuous glucose monitoring (CGM) data date range used to derive value. The terminal date should be used to assign assessment date.

PLEASE NOTE: "Most recent" means the closest to December 31 of the Measurement Year.


Acceptable Terminology:

A1c, HbA1c, HgbA1c

Glycohemoglobin

Glycohemoglobin A1c

Glycated hemoglobin

Glycosylated hemoglobin

Hemoglobin A1c


Not Acceptable Documentation

  • HbA1c self-tested when not processed by a lab
  • Documentation of ranges and thresholds do not meet criteria—Example: <9.0%
  • "Unknown" is not considered a result/finding
  • The member is not compliant if:
    • The most recent glycemic status assessment is >8.0%
    • Result is missing
    • A glycemic status assessment was not done during the measurement year

Eye Exam for Patients with Diabetes (EED)

Eligible Population

Members 18-75 years of age as of December 31 of the measurement year.

Enrollment

Member must be enrolled in a medical benefit during the measurement year.

Definition

The percentage of diabetic (type 1 and 2) members that have had screening or monitoring for diabetic retinal disease.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of the following test(s) or screening(s):  
TEST TYPE RESULTS  DOS (DATE OF SERVICE) WINDOW
A Retinal or Dilated Eye Exam Positive Results  Measurement Year
A Retinal or Dilated Eye Exam Negative Results Year prior to Measurement Year
Bilateral Eye Enucleation  N/A Any time during the member's history through 12/31 Measurement Year
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions: 
  • Palliative Care
  • Members in hospice or using hospice services anytime during the measurement year
  • Members who died any time during the measurement year
  • Frailty and Advanced Illness
  • Living in Long Term Care


*NOTE: Blindness is not an exclusion for a diabetic eye exam as it is difficult to distinguish between individuals who are legally blind but require a retinal exam and those who are completely blind and therefore do not require an exam.


EED Documentation Information:

Documentation in the medical record must include all of the following:

  • *Test performed (must indicate a dilated or retinal exam) or result
  • Date of service testing was performed
  • Care provider's credentials—must be performed by Optometrist or Ophthalmologist

*Test-Specific Information & Requirements:

1. Examination of the macula, vessels, and periphery without eye dilation meets criteria for a "retinal exam"

2. Prior year exam results must indicate retinopathy was not present

  • Documentation does not have to state specifically “no diabetic retinopathy” to be considered negative for retinopathy; however, it must be clear that the patient had a dilated OR retinal eye exam by an eye care professional (optometrist or ophthalmologist) and that retinopathy was not present.
    • An eye exam noted as positive for hypertensive retinopathy is counted as positive for diabetic retinopathy and an eye exam noted as negative for hypertensive retinopathy is counted as negative for diabetic retinopathy as both are handled the same.

3. Evidence that the member had bilateral eye enucleation OR acquired absence of both eyes

4. A chart or photograph with the date of fundus photography or retinal imaging AND one of the following:

  • Results read by a qualified reading center OR by a system that provides an artificial intelligence (AI) interpretation.
  • Results reviewed by an eye care professional.
  • Results read by a qualified reading center operating under the direction of a medical director who is a retinal specialist.
Not Acceptable Documentation

  • An eye exam result documented as "unknown" does not meet criteria
  • If one eye is not accessible, leading to an indeterminate result, this is not considered a result/finding
  • A statement that indicates "diabetes without complications" does not meet criteria 

Transition of Care (TRC)

Eligible Population

Members 18-75 years of age as of December 31 of the measurement year.

Enrollment

The date of discharge through 30 days after discharge (total of 31 days). Member must be discharged to home on or by December 1 of measurement year to remain in the measure.

Definition

The percentage of acute and non-acute discharges, on or between January 1 and December 1 of measurement year, for members 18 years of age and older who had each of the four elements through 30 days after discharge (31 total days):

- Notification of Inpatient Admission
- Receipt of Discharge Information
- Patient Engagement After Inpatient Discharge
- Medication Reconciliation Post-Discharge

Documentation submitted must include the following: 


Martin's Point star icon  Documentation supporting notification of inpatient admission:
TIMING INFORMATION NEEDED
Day of admission through two (2) days after the admission (three (3) total days). 
  • Phone calls
  • Emails, faxes
  • HIN/HIE, ADT transmissions/alerts
  • Note showing PCP or specialist admitted member and/or ordered tests
  • Preadmit exam by PCP or shared with PCP
AND  

Martin's Point star icon  Receipt of discharge information:
TIMING INFORMATION NEEDED
Receipt of discharge information on the day of discharge through two (2) days after the discharge (three (3) total days). 

Discharge information must include ALL of the following:

  • Practitioner responsible for the member's care during the inpatient stay
  • Procedures or treatment provided
  • Diagnosis at discharge
  • Current medication list
  • Testing results, or documentation of pending tests or no tests pending
  • Instructions for patient care post-discharge
AND  

Martin's Point star icon  Patient engagement:
TIMING INFORMATION NEEDED
 Documentation in the outpatient medical record must include evidence of patient engagement within 30 days after discharge.
  • An outpatient visit, including office vists and home visits
  • A telephone visit
  • A synchronous telehealth visit where real-time interaction occurred between the member and provider using audio and video communication
  • An e-visit or virtual check-in (asynchronous telehealth where two-way interaction, which was not real-time, occurred between the member and provider)


TRC Documentation Information:

Ongoing Care Provider (OCP)

The provider that assumes responsibility for the member's care following discharge:

  • A provider that ONLY provides care to the member while in the hospital is NOT considered an ongoing care provider.
  • The provider/specialist is not required to perform the engagement visit to be considered an ongoing care provider.
  • A provider/specialist may be considered an ongoing care provider if they provide care to the member in and out of the hospital.
  • A provider/specialist who only sees the member outside the hospital may still be considered an ongoing care provider.
    • Example: Planned procedure requiring hospital admission in which the member is seen prior to admission and following discharge.

Documentation in the PCP/OCP outpatient medical record must include ALL of the following:

1. Must include evidence of:

  • Notification of inpatient admission
  • Receipt of discharge information
  • Patient engagement after inpatient discharge
  • Medication reconciliation post-discharge

2. Date performed

3. Provider type:

  • Prescribing practitioner
  • Clinical pharmacist
  • Physician assistant
  • Registered nurse

Notification of Inpatient Admission

  • Documentation in the outpatient medical record must include evidence of receipt of notification of inpatient admission that includes evidence of the date when the documentation was received.
  • Evidence that the PCP or ongoing care provider communicated with the ED about the admission DOES meet criteria

 Not Acceptable Documentation for Notification of Admission:

  • Documentation that the member or the member’s family notified the member’s PCP or OCP of admission.
  • Documentation of notification that does not include a date when documentation was received or accessible to PCP or OCP.
  • When an ED visit results in an inpatient admission, notification that a provider sent the member to the ED does not meet criteria.

Receipt of Discharge

  • If the PCP or ongoing care provider is the discharging provider, the discharge information must be documented in the medical record on the day of discharge through two (2) days after the discharge (three (3) total days).

  • Shared EMR system:
    • Documentation of a “received date” in the EMR is not required to meet criteria.
    • Evidence that the information was filed in the EMR AND is accessible to the PCP or ongoing care provider on the day of discharge through 2 days after the discharge (3 total days) meets criteria.

 Not Acceptable Documentation for Receipt of Discharge:

  • Documentation the member or the member’s family notified the member’s PCP or OCP of discharge.
  • Documentation of notification that does not include a time frame or date when documentation received.
  • The presence of a discharge notification or discharge summary in the medical record alone does not count as evidence that the provider was aware of the hospitalization at the time of the follow-up visit (even if the provider was the discharging provider).

Patient Engagement

  • If the member is unable to communicate with the provider, interaction between the member’s caregiver and the provider meets criteria.
  • Patients transferring from a hospital to a skilled nursing facility or other inpatient setting require engagement after discharge from the skilled nursing facility or other inpatient setting.

 Not Acceptable Documentation for Patient Engagement:

  • Do NOT include patient engagement that occurs on date of discharge.

Determining Admission and Discharge Dates for TRC

ADMIT DATE: The date when member was first admitted.

  • Do not adjust the admit date if the discharge is preceded by an observation stay; use the admit date from the acute or nonacute inpatient stay.

DISCHARGE DATE: The date of the discharge where are are no readmissions or direct transfers within 31 days total.

  • If the discharge is followed by a readmission OR direct transfer to an acute OR nonacute inpatient care setting (do not include observation stays) on the date of discharge through 30 days after discharge (31 days total):
    • Use the admit date from the first admission and the discharge date from the last discharge.
  • If a member remains in an acute or nonacute facility through December 1 of the measurement year:
    • A discharge is not included in the measure for this member
  • If unable to confirm the member remained in the acute or nonacute care setting through December 1:
    • Disregard the readmission or direct transfer and use the initial discharge date.

Transition of Care (TRC) Medical Reconciliation

Eligible Population

Members 18-75 years of age as of December 31 of the measurement year.

Enrollment

The date of discharge through 30 days after the discharge (total of 31 days). Member must be discharged to home on or by December 1 of the measurement year to remain in the measure.

Definition

Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, physician assistant, or registered nurse, as documented through either administrative data or medical record review on the date of discharge through 30 days after discharge (31 total days) through 30 days after discharge (31 total days).

Documentation submitted must include ONE the following: 


Martin's Point star icon  Medical reconciliation information:
TIMING INFORMATION NEEDED

DOS

(Date of discharge through 30 days after discharge - 31 total days)
  • Documentation of the current medications with a notation that the provider reconciled the current and discharge medications.
  • Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, discontinue all discharge medications).
  • Documentation of the member’s current medications with a notation that the discharge medications were reviewed.
  • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service.
  • Preadmit exam by PCP or shared with PCP
  • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review. Evidence that the member was seen for post-discharge hospital follow-up requires documentation that indicates the provider was aware of the member’s hospitalization or discharge.
  • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence that the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
  • Notation that no medications were prescribed or ordered upon discharge.
OR  

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Members in hospice or using hospice services anytime during the measurement year
  • Members who died any time during the measurement year
  • Exclude both the initial and the readmission/direct transfer discharge if the last discharge occurs after December 1 of measurement year


TRC Medical Reconciliation Documentation Information
  • Post-Discharge Follow-Up: Evidence must support provider was aware of hospitalization.
    • Documentation must include mention of “hospitalization”, “admission”, or “inpatient stay” OR reference to reconciliation of current and discharge medications in the note.
      • Reference to hospitalization must include dates of admission and D/C in case there are multiple admissions/ discharges.
  • Patients transferring from a hospital to a skilled nursing facility (SNF) or other inpatient setting DO NOT require medication reconciliation until they are discharged from the inpatient setting.

Not Acceptable Documentation

  • Documentation of “post-op/surgery follow-up” without specifically referencing a “hospitalization”, “admission”, or “inpatient stay” does not imply a hospitalization and is not considered evidence that the provider was aware of a hospitalization.
  • Documentation that only supports that the provider was aware of the surgery (even if the procedure/surgery is typically performed inpatient) OR if the provider performed the surgery is not sufficient to show that the provider was aware of the “hospitalization” at the time of the follow-up visit.
  • The presence of a discharge notification or discharge summary in the medical record alone does not count as evidence that the provider was aware of the hospitalization at the time of the follow-up visit (even if the provider was the discharging provider).

Kidney Health Evaluation for Patients with Diabetes (KED)

Eligible Population

Members 18-75 years of age as of December 31 of the measurement year.

Enrollment

The measurement year.

Definition

The percentage of members 18-85 years of age with diabetes (type 1 and type 2) as of December 31 of the measurement year who receive a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR) during the measurement year.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of one set of the following test(s) or screening(s):  
TEST TYPE DOS (DATE OF SERVICE) WINDOW

eGFR (estimated glomerular filtration rate)

AND

uACR (urine albumin creatinine ratio) 

 01/01 Measurement Year–12/31 Measurement Year

Quantitative Urine Albumin Test 

AND

Urine Creatinine Test 

 01/01 Measurement Year–12/31 Measurement Year
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • End-stage renal disease (ESRD)
  • Dialysis
  • Palliative Care
  • Members in hospice or using hospice services anytime during the measurement year
  • Members who died any time during the measurement year
  • Frailty and Advanced Illness
  • Living in Long Term Care


KED Documentation Information:
  • A quantitative urine albumin test and a urine creatinine test require service dates four or less days apart.
  • Documentation received that does not support that both an eGFR AND a uACR were completed is not compliant. Both must be completed to be compliant.

Follow-Up After Emergency Department Visit for People with Multiple High-Risk, Chronic Conditions (FMC)

NOTE ON ELIGIBILITY: ED visits are counted for members with two or more different chronic conditions prior to the ED visit. A list of eligible chronic conditions can be found further below.

Eligible Population

Members 18 years and older as of the ED visit.

Enrollment

365 days prior to ED visit through seven (7) days after the ED visit.

Definition

The percentage of emergency department (ED) visits for members 18 years of age and older who have multiple high-risk, chronic conditions who had a follow-up service within seven (7) days of the ED visit.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of a follow-up service after the ED visit:  

7-Day Follow-Up: A follow-up service within seven (7) days after the ED visit (eight (8) total days).

THE FOLLOWING MEET CRITERIA FOR FOLLOW-UP:
  • An outpatient visit
  • A telephone visit
  • Transitional care management services
  • Case management visits
  • Complex Care Management Services
  • An outpatient of telehealth behavioral health visit
  • An intensive outpatient encounter or partial hospitalization
  • A community mental health center visit
  • Electroconvulsive therapy
  • A telehealth visit
  • An observation unit
  • A substance-use disorder service
  • An e-visit or virtual check-in
  • A domiciliary or rest home visit
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Exclude ED visits that result in an inpatient stay
    • ED visits followed by admission to an acute or nonacute inpatient care setting on the date of the ED visit or within 7 days after the ED visit, regardless of the principal diagnosis for admission.
      • These events are excluded from the measure because admission to an acute or nonacute setting may prevent an outpatient follow-up visit from taking place.
  • Members in hospice, using hospice services, or elect to use a hospice benefit any time during the measurement year
  • Members who died any time during the measurement year

     

Eligible Chronic Conditions:

The following are eligible chronic condition diagnoses. Each bullet indicates an eligible chronic condition (for example: COPD and asthma are considered the same chronic condition):

  • COPD, asthma, or unspecified bronchitis
  • Asthma Diagnosis Value
  • Alzheimer's disease and related disorders
  • Frontotemporal Dementia
  • Chronic kidney disease
  • Depression
  • Heart failure
  • Acute myocardial infarction
  • Atrial fibrillation
  • Stroke and transient ischemic attack
  • If a member has more than one ED visit in an 8-day period, include only the first eligible ED visit.
  • Eligible chronic condition diagnoses are identified on the discharge claim, on different dates of service, during the measurement year or year prior.
    • Visit type does not need to be the same for the two visits, but the visits must be for the same eligible chronic condition.
    • At least two outpatient visits ED visits, telephone visits, e-visits or virtual check-ins, nonacute inpatient encounters or nonacute inpatient discharges.
  • Visits are identified chronologically. Only one visit per 8-day period.
    • If a member has more than one ED visit in an 8-day period, only the first eligible ED visit is included.

Osteoporosis Management in Women with a Fracture (OMW)

Eligible Population

Women 67-85 years of age as of December 31 of the measurement year.

Enrollment

365 days prior to the episode date through 180 days after the episode date.

Definition

The percentage of women 67-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the 180 days (six months) after the fracture.

Documentation submitted must include ONE of the following: 


Martin's Point star icon  Documentation of OMW compliant treatment(s) or screening(s):  
TEST TYPE DOS (DATE OF SERVICE) WINDOW

Bone Mineral Density (BMD) Test

 Any setting on date of fracture or in the 180-day (six month) period after.

Bone Mineral Density (BMD) Test - Inpatient Stay

 BMD test during the inpatient stay.
Therapy or Prescriptions - Osteoporosis therapy or a dispensed prescription to treat osteoporosis Any setting on date of fracture or in the 180-day (six month) period after.
Long-acting Osteoporosis Therapy During the inpatient stay on the date of fracture or in the 180-day (six month) period after.
OR   

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Members in hospice or using hospice services anytime during the measurement year.
  • Members who died any time during the measurement year
  • Palliative Care
  • Frailty, Frailty and Advanced Illness, Living in Long Term Care
  • Members who had a BMD test during the 24 months prior to the fracture
  • Members who had osteoporosis therapy during the 12 months prior to the fracture
  • Members who were dispensed a medication or had an active prescription for medication to treat osteoporosis during the12 months prior to the fracture
  • Documentation that the medications aren’t tolerated is not an exclusion for this measure.

A referral for a BMD is not enough to support that the test was completed and is not compliant.

Statin Therapy for Patients with Cardiovascular Disease (SPC) - Received

Eligible Population

Males 21-75 years of age and females 40-75 years of age as of December 31 of the measurement year.

Enrollment

180 days prior to the IPSD (index prescription start date) through 61 days after the IPSD.

Definition

The percentage of males 21-75 years of age and females 40-75 years of age as of December 31 of the measurement year, diagnosed with a clinical atherosclerotic cardiovascular disease (ASCVD) and were dispensed at least one high or moderate-intensity statin medication during the measurement year.

Documentation submitted must include the following:


Martin's Point star icon  Documentation supporting member received Statin Therapy with the following:
  • Name of medication dispensed
  • Date of service dispensed
AND           

Martin's Point star icon  Members must meet the following requirements:
  • Diagnosis of a myocardial infarction and/or old myocardial on the discharge claim, AND
  • CABG, PCI or any other revascularization in any setting the year prior to the measurement year, OR

 

  • Members diagnosed with ischemic vascular disease (IVD) who met at least one of the following criteria during both the measurement year AND the year prior to the measurement year:
    • At least one outpatient visit, telephone visit, e-visit or virtual check-in with an IVD diagnosis.
    • At least one acute inpatient encounter with an IVD diagnosis without telehealth.
    • At least one acute inpatient discharge with an IVD diagnosis on the discharge claim.
OR         

Martin's Point star icon  Documentation supporting one or more of the following required exclusions:
  • Members in hospice or using hospice services anytime during the measurement year.
  • Members who died any time during the measurement year
  • Palliative Care
  • Frailty, Frailty and Advanced Illness, Living in Long Term Care
  • Myalgia, myositis, myopathy or rhabdomyolysis during the measurement year
  • Myalgia or rhabdomyolysis caused by a statin anytime during member’s history through December 31 of the measurement year
  • ONE of the following during the measurement year or the year prior:
    • Pregnancy
    • In vitro fertilization
    • Dispensed at least one prescription for clomiphene
    • ESRD or dialysis
    • Cirrhosis
*Martin’s Point will continue to collect data for HEDIS review beyond the Star Measures during the Measurement Year


Key Terms and Additional Information

A glossary of commonly-used words and other helpful information can be found below.

Anchor dates

A measure may require a member to be enrolled and to have a benefit on a specific date.


Denominator

Number of members who qualify for measure criteria, based on NCQA technical specifications.


Element

Measurable way a HEDIS measure is broken down and defined and is referred to as a sub-measure.


Eligible Population

Includes all members who meet all specified criteria, including age, continuous enrollment, benefit, event and the anchor date enrollment requirement for the measure.


Electronic clinical data systems (ECDS) Measures

Data systems that may be eligible for ECDS reporting include, but are not limited to, administrative claims, clinical registries, health information exchanges, immunization information systems, disease/case management systems and electronic health records.


HEDIS Measure

Term for how each domain of care is further broken down. Specifications outline measure definition and details, which outline the specifications required to evaluate the recommended standards of quality for the element(s) in the measure.


Measurement Year (MY)

Refers to the year prior to the Reporting Year.


Numerator

The number of members who meet compliance criteria based on NCQA technical specifications for appropriate care, treatment or service.


Ongoing care provider (OCP)

The practitioner who assumes responsibility for the member’s care.


Primary Care Practitioner (PCP)

A physician or non-physician (e.g., nurse practitioner, physician assistant, certified nurse midwife) who offers primary care medical services.


Prior Year (PY)

Year prior to measurement year.


Supplemental Data (Non-Standard)

Medical records that are manually extracted from the member's medical record and submitted as proof of service for the specified measure.


Supplemental Data (Standard)

Electronically generated files that come from providers who rendered a particular service (ex: claims,encounters,etc.).


Sub-measure

A measure can be broken down into more specific data elements of care.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The HEDIS® measures and specifications were developed by and are owned by NCQA. The HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures and specifications. NCQA holds a copyright in these materials and can rescind or alter these materials at any time. These materials may not be modified by anyone other than NCQA. Anyone desiring to use or reproduce the materials without modification for an internal non-commercial purpose may do so without obtaining any approval from NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted adjustments of the materials does not constitute a modification. All other uses, including a commercial use and/or external reproduction, distribution and publication must be approved by NCQA and are subject to a license at the discretion of NCQA.

Reprinted with permission by NCQA. © 2026 NCQA, all rights reserved.



Provider Manual content reviewed and updated as of January 1, 2026.