HEDIS® Compliance Audit™ and Supplemental data Wendy Talbot, MPH Director, Measure Validation – Audit and Data Collection

Why a Standardized Audit? Accuracy Consistency Comparability

HEDIS Reporting Data Sources HEDIS rates are made up several types of data. Claims/encounter Enrollment Provider Medical record Supplemental    

Uses for Supplemental Data Data besides claims/encounter and medical record Supplemental data may be used to determine: the numerator optional exclusions eligible-population required exclusions Supplemental data may not be used to determine: denominator events chronic conditions that change overtime correct bills or identifying valid data errors

Supplemental Data Validation Standard supplemental data Electronically generated files from service providers (providers who rendered the service) Files have clear policies & procedures; use standard file layouts that remain stable year to year, field and industry-standard codes All elements are provided to meet the measure specifications Examples: Laboratory results files Current or historic state transaction files Immunization data from state or county registries Transactional data from behavioral health vendors EHR vendor systems Data from certified eMeasure vendors

Supplemental Data Validation Nonstandard supplemental data Collected/created by organization or vendor; captures service data not in claims, encounters, or standard electronically generated files Collected/created from sources on an irregular basis and may be in files or formats that are not stable over time Must have clear policies and procedures describing how the data are collected and by whom, how they are validated and used for reporting Examples: EHR modules (e.g., uncertified eMeasure modules) Provider portals (i.e., electronic systems providers use to enter information about services rendered) Health Information registries Provider abstraction forms Records from services rendered or information collected during home visits Member-reported data

Supplemental Data Validation Standard supplemental data Files are not required to be accompanied by proof-of-service documents, and audit should not required PSV unless requested by auditor. Nonstandard supplemental data All data must be substantiated by proof-of-service documentation from the legal health record. Proof-of-service is required for only a sample as part of the audit’s annual PSV. *Nonstandard can move to standard when auditors are comfortable with it and have approved it for use in previous years.