Quality resources for providers

Like you, we work to continually improve the quality of our services for the members who entrust us with their care. Here you will find resources to help us work together to improve healthcare quality for the members who need it most. 

HEDIS® measures

The Healthcare Effectiveness Data and Information Set (HEDIS®) is one of healthcare’s most widely used performance improvement tools. HEDIS measures and specifications are published by the National Committee for Quality Assurance (NCQA) to help objectively evaluate and compare performance and quality across health plans, including Medicare, Medicaid and commercial plans.

HEDIS includes more than 80 measures which are aggregated to rate the effectiveness of care, member experience, and the appropriate coding of care received. Learn more in our HEDIS General Guidelines.

HEDIS tip sheets

The tip sheets below can be used to help you improve on select HEDIS measures.

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Access/Availability of care
  • Use of First-Line Psychosocial Care for Children and Adolescent on Antipsychotics (APP)
  • Initiation and Engagement of Substance Use Disorder Treatment (IET)
  • Prenatal and Postpartum Care (PPC)
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Prevention and screening
  • Childhood Immunization Status (CIS/CIS-E)
  • Care of Older Adults (COA)
  • Immunizations of Adolescents (IMA/IMA-E)
  • Lead Screening in Children (LSC)
Diabetes
Diabetes
  • Blood Pressure Control for Patients with Diabetes (BPD)
  • Eye Exam for Patients with Diabetes (EED)
  • Glycemic Status Assessment for Patients with Diabetes (GSD)
  • Kidney Health Evaluation for Patients with Diabetes (KED)
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Behavioral health
  • Follow-Up After Emergency Department Visit for Substance Use (FUA)
  • Follow-up After Hospitalization for Mental Illness (FUH)
  • Follow-up After Emergency Department Visit for Mental Illness (FUM)
  • Pharmacotherapy for Opioid Use Disorder (POD)
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Care coordination
  • Transitions of Care (TRC)
Heart
Cardiovascular conditions
  • Controlling High Blood Pressure (CBP)
Asthma Inhaler
Respiratory conditions
  • Asthma Medication Ration (AMR)
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Utilization
  • Child and Adolescent Well-Care Visits (WCV)
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Electronic clinical data systems (ECDS)
  • Breast Cancer Screening (BCS-E)
  • Colorectal Cancer Screening (COL-E)
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Additional resources

 

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Helpful resources

Quality rating programs

The Quality Rating System (QRS) is a quality reporting program that compares the performance of Qualified Health Plans (QHP) offered on Exchanges and accounts for both the quality of provided healthcare services and the health plan administration. CMS calculates ratings on a 1-to-5 scale (5 is the highest) each year for eligible QHPs in all Exchanges.

The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Advantage (Medicare Part C) and Medicare Part D Star Ratings each year to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans). The Star Ratings system helps Medicare consumers compare the quality of Medicare health and drug plans being offered so they are empowered to make the best health care decisions for them. An important component of this effort is to provide Medicare consumers and their caregivers with meaningful information about quality alongside information about benefits and costs to assist them in being informed and active health care consumers.

The Centers for Medicare & Medicaid Services (CMS) developed the Medicaid and Children’s Health Insurance Program (CHIP) Scorecard to improve transparency and accountability about the administration and outcomes of these programs. States and CMS can use the Medicaid and CHIP (MAC) Scorecard to drive improvements in areas such as state and federal alignment, beneficiary health outcomes, and program administration. 

NCQA’s Health Plan Ratings 2024 include commercial, Medicare and Medicaid health plans. The overall rating is the weighted average of a plan’s HEDIS® and CAHPS® measure ratings, plus bonus points for plans with a current Accreditation status as of June 30, 2024.

Best practices

We've compiled a list of resources below to help you follow best practices when it comes to patient care.

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