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Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA). Through HEDIS, NCQA compares Aetna Better Health® of Illinois to other health plans. It also holds us accountable for the timeliness and quality of health care services (acute, preventive, mental health, etc.) delivered to our diverse membership.

Use of HEDIS scores

As state and federal governments move toward a health care industry driven by quality, HEDIS rates are becoming more and more important to the health plan, the individual and the provider. State purchasers of health care use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts. Physician-specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs.

HEDIS and HIPAA

As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations is permitted by HIPAA privacy rules (45 CFR 164.506). It also doesn’t require consent or authorization from the member or patient. The medical record review staff and/or vendor will have a signed HIPAA-compliant Business Associate.

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