UnitedHealthcare® Quality Reference Guide 2020/21 HEDIS,® CMS Part D, CAHPS® and HOS Measures HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). Information contained in this guide is based on NCQA HEDIS® technical specifications. For more details, please visit ncqa.org. ©2021 United HealthCare Services, Inc. We have the same goal: To help improve your patients’ health outcomes by identifying and addressing open care opportunities. Like you, we want your patients, who are UnitedHealthcare plan members, to be as healthy as possible. And a big part of that is making sure they get the preventive care and chronic care management they need. To help identify care opportunities, our PATH program gives you information specific to UnitedHealthcare members who are due or overdue for specific services. This reference guide can help you better understand the specifications for many of the quality measurement programs and tools used to address care opportunities, as well as how to report data and what billing codes to use. For additional PATH resources or to access this guide online, please visit UHCprovider.com/path. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Company of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company, or other affiliates. Administrative services provided by OptumHealth Care Solutions, LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc., or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), or its affiliates. PCA-1-21-02879-Clinical-WEB_08012021 By working together, we can achieve our shared goals. HEDIS® Measures CAHPS® Measures Healthcare Effectiveness Data and Information Set (HEDIS®) Consumer Assessment of Healthcare Providers and is a National Committee for Quality Assurance (NCQA) tool Systems (CAHPS) is an annual survey that asks consumers used by more than 90 percent of America's health plans and members to report on and evaluate their experiences to measure performance on important dimensions of care with health care. The CAHPS® survey is governed by CMS and service. and NCQA. • HEDIS® measures are reported as administrative or • The survey is given annually between Feb. and June hybrid and are collected and reported annually by to adults ages 18 and older who have been enrolled health plans. in a health plan during a continuous six-month period • The data collection cycle, which includes gathering for Medicare and Medicaid, or a 12-month period for medical record information from care providers, commercial. For Medicaid only, guardians of children generally happens in the first half of each year. ages 17 and younger are also given the survey if they’ve been enrolled in a plan for a continuous • The data is then used to evaluate quality of care, which six-month period. is determined by dividing the measure numerator by the measure denominator. • Respondents are asked a core set of questions determined by NCQA and CMS, in addition to a series of HEDIS®-related terms are explained in the Glossary. optional supplemental questions crafted by a health plan and approved by NCQA and CMS. CMS Measures • Members are given the option to complete the survey Centers for Medicare & Medicaid Services (CMS) Part D by mail, phone or online. medication adherence measures are used to help increase • Results are calculated and released between July the number of Medicare members taking their cholesterol and Oct. (statin), diabetes and/or hypertension (RAS antagonist) medications as prescribed. Members are eligible for a HOS Measures measure if their medication appears on a targeted list Health Outcomes Survey (HOS) is a health plan member provided by the Pharmacy Quality Alliance (PQA). Their survey by CMS that gathers health status data specific adherence is then evaluated using the proportion of days to the Medicare Advantage program. Respondents are covered (PDC), which is defined in the Glossary. given a baseline survey between late Aug. and Nov. and • CMS considers Medicare members adherent if then asked to complete a follow-up survey two years later their PDC is 80 percent or more at the end of the between Aug. and Nov. measurement period. Baseline survey results are calculated and released in May • Member eligibility and performance within the Part D of the following year, while results for the follow-up survey medication adherence measures is based entirely on are provided during the summer of the following year. prescription claims processed at the pharmacy under the Part D benefit. • Supplemental data from medical records or patient assessments can’t be used to affect these measures. PCA-1-21-02879-Clinical-WEB_08012021 Glossary of Terms New for 2021 Medical Record Data The information taken directly from a member’s medical E-Visit or Virtual Check-In record to validate services rendered that weren’t captured These visit types fall under telehealth for purposes of NCQA through medical or pharmacy claims, encounters or and HEDIS® reporting. These interactions are not “real-time” supplemental data. but still require two-way interaction between the member and provider (e.g., a patient portal, secure text messaging or email). Collection and Reporting Method • Administrative – Measures reported as administrative Phone Visits use the total eligible population for the denominator. CPT®/CPT® II – 98966-68, 99441-43 Medical, pharmacy and encounter claims count toward the numerator. In some instances, health plans use Online Assessment (e-visit/virtual check-in) approved supplemental data for the numerator. CPT®/CPT® II – 98969-72, 99421-23, 99444, 99457 HCPCS – G0071, G2010, G2012, G2061, G2062, G2063 • Hybrid – Measures reported as hybrid use a random sample of 411 members from a health plan’s total eligible population for the denominator. The numerator includes Measurement Year medical and pharmacy claims, encounters and medical In most cases, the 12-month timeframe between which record data. In some cases, health plans use auditor- a service was rendered – generally Jan.1 – Dec. 31. approved supplemental data for the numerator. Data collected from this timeframe is reported during the • Supplemental Data – Standardized process in which reporting year. clinical data is collected by health plans for purposes of HEDIS® improvement. Supplemental clinical data is Reporting Year additional data beyond claims data. The timeframe when data is collected and reported. The service dates are from the measurement year, which is Required Exclusion usually the year prior. In some cases, the service dates may Members are excluded from a measure denominator based go back more than one year. on a diagnosis and/or procedure captured in their claim/ Example: The 2021 reporting year would include data from encounter/pharmacy data. If applicable, the required services rendered during the measurement year, which exclusion is applied after the claims data is processed within would be 2020 and/or any time prior. Results from the certified HEDIS® software while the measure denominator is 2021 reporting year would likely be released in June 2021, being created. For example: depending on the quality program. • Members with end-stage renal disease (ESRD) during the measurement year or year prior will be excluded from Denominator the statin therapy for patients with cardiovascular disease The number of members who qualify for the measure (SPC) measure denominator. criteria, based on NCQA technical specifications. • Members with a claim for hospice services during the measurement year will be excluded from all Numerator applicable measures. The number of members who meet compliance criteria based on NCQA technical specifications for appropriate care, treatment or service. PCA-1-21-02879-Clinical-WEB_08012021 Glossary of Terms Optional Exclusion Proportion of days covered (PDC) Members are excluded from a measure denominator According to the Pharmacy Quality Alliance (PQA), the PDC manually using certified HEDIS® software during the hybrid is the percent of days in the measurement period covered by review process, also known as medical record review. prescription claims for the same medication or another in its For example: therapeutic category. • Members who had a total colectomy when they weren’t enrolled in a UnitedHealthcare plan will be excluded from the colorectal cancer screening (COL) measure after a hybrid review and appropriate documentation is provided. • Women with evidence of a total hysterectomy (no residual cervix) will be excluded from the Cervical Cancer Screening (CCS) measure after hybrid review and appropriate documentation is provided. Applicable optional and required exclusions