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

2. Why a Standardized Audit?
Accuracy
Consistency
Comparability

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

4. 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

5. 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

6. 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

7. 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.