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HEDIS (Healthcare Effectiveness Data and Information Set)
HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds Western Sky Community Care accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.

Use of HEDIS Scores
As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare 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.

Calculating HEDIS Rates
HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, routine Pap test, appropriate treatment of pharyngitis, appropriate treatment of URI, appropriate treatment of asthma, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care, and well-child care.

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) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.

Behavioral Health HEDIS Trainings

Western Sky Community offers Behavioral Health HEDIS Training for Providers in order to share information and strategies to providers to positively impact quality care and outcomes for our members and help providers recognize the intent of the BH HEDIS measures and review and/or share strategies to impact quality care and outcomes for those that they serve. The on-Demand Training also provide information on the Experience of Care and Health Outcomes (ECHO) Survey. Western Sky offers a live instructor-led webinar as well as makes BH On-Demand training through Centene aviable to providers. For additional HEDIS information, please see HEDIS (

Webinars: Educational opportunities facilitated by a trainer online.

Training Title: Strategies to Improve Care, Coordination, Outcomes, and Customer Experience: Optimizing the Impact of Behavioral Health HEDIS® Measures.

To register, please click here for topics, dates/times, continuing education availability, and other information.

On-Demand Topics: Educational opportunities that are available on demand and that are self-paced.

Training Title: Centene BH HEDIS On-Demand Trainings

Purpose: Each 8-20 minute training includes strategies to positively impact quality care and outcomes for our members and help providers recognize the intent of the BH HEDIS measures and the Experience of Care and Health Outcomes (ECHO) Survey. 

Audience: Medical and Behavioral Health Providers and office staff 

To view the training(s), click on the title link, enter work email and complete registration for tracking and reporting purposes.

Strategies to Minimize the Risk of Opioid Overuse and Misuse

Optimizing the Impact of the ADD and APP HEDIS® Measures

Initiation and Engagement, Follow-Up After Emergency Department or High Intensity Care for Substance Use Disorders: Optimizing the IET, FUA, and FUI HEDIS® measures

Strategies to Improve Cardiovascular, Diabetes, and Metabolic Monitoring: APM, SSD, SMC, and SMD HEDIS® Measures

Follow-Up Care After a Hospital or Emergency Department Visit for Mental Illness: Optimizing the FUH and FUM HEDIS® Measures

Antidepressant Medication Management and Antipsychotic Medication Adherence: Optimizing the AMM and SAA HEDIS® Measures

Enhancing Member Experience with Behavioral Health Care Services: Experience of Care and Health Outcomes (ECHO) Survey