Skip to main content

Introduction to Behavioral Health HEDIS

A comprehensive overview and introduction into NCQA, HEDIS, Behavioral Health HEDIS measures, the role of the Clinical Quality Improvement Liaison and other helpful Horizon resources.

Introduction to Behavioral Health HEDIS


Hello, and thank you for attending the Behavioral Health Quality Program's presentation, an Introduction to Health Care Effectiveness Data and Information Set, also known as, HEDIS. This presentation is provided in part by Horizon's, Behavioral Health HEDIS team. For more information about this and future presentations, please reach out to your assigned behavioral health Clinical Quality Improvement Liaison, or you can utilize the general behavioral health, HEDIS team email that will be provided at the conclusion of today's presentation. Thank you again for joining us, and we hope that you will consider attending future presentations.

Our objective for this presentation is that you will have an improved understanding of the following: Horizon goals; NCQA and HEDIS; Medicare Stars, Behavioral Health HEDIS measures, the role of the Clinical Quality Improvement Liaison or CQIL; and lastly, that you will be able to access additional resources from Horizon to help you improve the quality of care provided to our members.

Horizon's goal for the quality programs is to improve clinical outcomes and performance on HEDIS measures and promote the care our members receive.

The National Committee for Quality Assurance also known as NCQA is a private non-profit organization focused on quality of care. NCQA provides accreditation to a wide range of healthcare organizations and it helps Horizon meet the goal of accreditation requirements in promoting supportive care that keeps members at optimum levels of health while controlling costs and meeting government and purchaser requirements. When you see the NCQA seal on a health plan's materials that indicates that the plan has met the set guidelines for standardized quality performance measures. NCQA is committed to providing consumers with the information, needed to find high quality health care providers and plans.

If you are not already familiar with HEDIS, it is an acronym that stands for health care effectiveness, data and information set. HEDIS was developed by the National Committee for Quality Assurance, and it is a set of standardized performance measures. It ensures the public has the information it needs to compare organization performance. HEDIS is not exclusive to Horizon. 90% of America's health plans use HEDIS to measure performance, and there are a total of 95 HEDIS measures. Today's presentation will focus specifically on our behavioral health HEDIS measures.

Now that we've reviewed NCQA and HEDIS, we are going to take a look at what's behind the Medicare Star rating. The Centers for Medicare and Medicaid also known as CMS, uses a Star ratings program to compare the performance of health plans in several categories. The Star rating program uses a 5-Star rating for meeting the thresholds or cut points. CMS determines the cut points by applying a clustering algorithm, which results in the creation of the 5 levels of the Star rating. As a result, a Star rating with levels of 1 through 5 are assigned with 1 being the lowest and 5 being the highest. When a plan reaches a 4 and 5 Star ratings, the quality bonus payments are then transferred to the members who receive better member benefits. The annual highlighted cap survey holds the highest weight as it relates to calculating Horizon's, overall Star rating or one third of Star weights. This means the member experience is becoming more and more important. Survey results are publicly reported on the Medicare Plan Finder, also known as Plan Compare for consumers to shop and compare Medicare Advantage and prescription drug plans and it is also posted on and that website is listed at the bottom left of this screen.

HEDIS is important to Horizon for various reasons. The measures help to obtain and maintain accreditation requirements. It improves health plan, delivery and services, and the quality measures reduces gaps in care. It also evaluate clinical quality performance. It improves outcomes for members, which reduces costs of care. And, it enables data to identify at risk populations. And lastly, information from HEDIS reports help to create the annual state of health care quality report from NCQA.

How does HEDIS measure performance? In order to monitor HEDIS measure performance, NCQA defines each HEDIS measure and identifies the eligibility and the compliance criteria. They use claims data as the primary source. And, they collect the data as a year-round process. This enables the health plans and providers to close gaps in care, resulting in improved member outcomes and enhanced quality of care.

This slide introduces some of the commonly used terminology by NCQA regarding HEDIS: First, we have eligible population or initial population which defines the broadest group of population for inclusion in the measure. The denominator describes the population evaluated by the individual measure, which may not be the same as the initial population. Next, the numerator describes the process, condition, event or outcome that satisfies the measure focus or intent. And, finally the exclusion describes individuals in the denominator, but are not eligible for the outcome due to a specific reason, particularly where their inclusion may bias the results.

The following are some identified barriers to improving behavioral health care quality measures. Disjointed accountability, lack of incentives or demand, thin evidence and changing policies. Different cultures, access to or reliance on claims data and limited focus on outcomes.

NCQA's goal is to advance health equity for disparities in care among patient populations. This slide overviews, some changes. New for measurement year 2023 NCQA has introduced the race and ethnicity stratification for two of the behavioral health HEDIS measures: Follow up after emergency department visits for substance use, or FUA; And, Initiation and engagement of substance use disorder treatment, or IET. Race stratifications include: white, black, or African American, American Indian, or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander or some other race, 2 or more races asked, but no answer and unknown. And the ethnicity includes Hispanic or Latino, non-Hispanic or Latino, asked, but no answer and unknown. The two reported age stratifications and a total rate remain the same as last measurement year and it includes 13 to 17 years of age, and 18 years of age and older. NCQA also introduced a new HEDIS measure for measurement year 2023. The social needs screening and intervention, or also known as, SNS-E. NCQA developed this measure to advance health equity by acknowledging social factors such as access to food, housing, transportation and social supports that contributes significantly to health outcomes. Although this measure is not currently owned by the behavioral health HEDIS team Horizon as an organization is monitoring this, and we want to share this updated information with our providers. Lastly, NCQA HEDIS added a required exclusion for all Behavioral Health HEDIS measures. Members who died during the measurement year is now a required exclusion.

At Horizon, we continue to help our members achieve their best health by addressing health care disparities related to race and social barriers our member's face in accessing care. Horizon has and continues to deploy the most comprehensive effort yet in New Jersey to remove barriers that prevent Horizon, Blue Cross, Blue Shield members who are living in underserved communities from achieving their best health by connecting at risk members to services that are vital to their health and wellbeing. Horizon has also directed 80% of the Horizon Foundation for New Jersey, charitable giving to organizations that support people of color and are working to close health care, disparities, improve, care, access, and create prevention and awareness programs for major diseases. Horizon is also increasing the diversity of their network of physicians, nurses and behavioral health providers. And, they are incorporating a bias training requirement into the network provider relationships. Horizon is also creating a scholarship initiative to increase the number of black nursing students in New Jersey. And finally, Horizon is partnering with government agencies and community organizations to close racial health disparities and improve maternal and infant care.

Now, we will take a look at the behavioral health HEDIS measures.

This slide lists in blue, 11, behavioral health HEDIS measures that Horizon currently monitors and for which data is collected. As you can see not all of the behavioral health HEDIS measures apply to every line of business. The X next to each measure indicates which product line the data is collected: Either, Medicaid, Medicare, or commercial. Even though every measure may not apply to every line of business or plan, we still want recommend adhering to the best practice suggestions, regardless if we are monitoring these measures or not. As we want to ensure, we are providing the highest quality of care to our members. It is important to note that the 2 measures highlighted in red are not current behavioral health owned measures. While the behavioral health team is not tasked with the performance rates for SMC or SMD, they do relate to our members so we monitor their performance. For the purpose of today's presentation, we will not be reviewing each measure in detail. However, the behavioral health HEDIS educational series offers additional presentations grouped into 3 categories: 1) reviews HEDIS measures, specific to the treatment of children and adolescents; The 2nd, reviews measures, which apply to the treatment of mental health for the adult population; And the 3rd training provides an overview of the HEDIS measures specific to the treatment of substance use disorders. If you are new to HEDIS, or you are treating members in these populations, we hope you will consider participating in other trainings within this series and show this information with any interested members of your teams. These trainings take a deeper dive into specifics of the eligible population, how providers meet measure compliance, and the suggested best practices.

The next few slides will review the role of the behavioral health, Clinical Quality Improvement Liaison or CQIL.

The behavioral health team at Horizon includes several behavioral health, specific, Clinical Quality Improvement Liaisons, or CQILs. In network behavioral health providers have access to a dedicated CQIL team who will collaborate with their practice by supporting the goal of improving HEDIS quality performance and care provided to our members. The CQILs can assist providers with a comprehensive variety of tools, including resources, education, data, and practice transformation with the objective to enhance treatment delivery. The CQILs can also help with meeting HEDIS by acting as the single point of contact within Horizon to assist with navigating NCQA/HEDIS; Providing a variety of resources, tools and webinars to improve HEDIS knowledge; Assisting to analyze quality performance reports and addressing barriers to care; and ongoing collaboration to promote best practices.

This slide contains the names of the 5 CQILs on the behavioral health HEDIS team along with their contact information. We also have an email set up for general, behavioral health, HEDIS related inquiries that we check regularly and share with providers, which you can see listed here at the bottom of the slide.

If you have not been assigned to partner with one of our behavioral health CQILs, we encourage you to utilize the general team email for any questions or requests.

Our behavioral health HEDIS team also has a variety of HEDIS specific provider tools, designed to empower our providers with NCQA best practice guidelines for improving clinical quality of care. Our CQILs can collaborate with your team to share and review resources that permit improve patient outcomes and HEDIS performance.

Horizon's online quality resource center contains various supports, designed to assist providers, ongoing efforts in delivering quality services to their patients. The quality resource center web address is located at the top of this slide. Here you can find links to resources, including the Provider Tips for Optimizing HEDIS results booklet, the HEDIS and Quality Management Program Manual, the HEDIS Measure Guidelines, Interactive HEDIS Guidelines, information regarding the Results and Recognition program as well as previously recorded provider educational webinars.

Another provider resource that is available is Horizon's, HEDIS Measure Guidelines for behavioral health via the website. Each link provides a summarize NCQA best practice recommendations along with a link to access the provider billing tips booklet.

From there, each behavioral health HEDIS link provides summarized NCQA best practice recommendations. The Provider Billing Tips Booklet allows you to access the corresponding quality tips codes along with the HEDIS documentation requirements. Please note that the provider tips link includes HEDIS quality value- set codes, set forth by NCQA. As such your assigned CQIL is not authorized to advise providers how and what to code. Providers are encouraged to utilize the resources provided in accordance with services rendered, and the appropriate documentation noted in the medical records when utilizing the HEDIS suggested value sets.

Horizon understands that as a provider in our network, your role is crucial in improving patient outcomes. Next, we will review some of Horizon's resources available to members and providers.

Horizon Healthy Journey Program is a great resource for our network providers and our members.

The department consists of a dedicated population health management team whose focus is to outreach members through various methods in helping to remind them of preventative care services and offering opportunities for education and chronic disease management. The number for our healthy journeys team is listed here to contact them directly if you have any questions or to share this phone number with your patients. Outreaches include live calls, interactive, voice recognition calls, direct mailings and member reward programs just to name a few.

Another resource available to our members is Horizon's Care Management team. The Care Management team is a unique opportunity for members to collaborate with our clinical team and efforts to educate and coordinate care. Members with an assigned Care Manager may receive updates on various programs and vendors. Members who qualify for Care Management and have agreed to engage in the program need to complete assessments based on program criteria. The risk level scoring will indicate the level of Care Management interventions. If the member is enrolled, they will be assessed through additional outreach and receive assistance from our Care Management teams. If you think someone may benefit from one of our Care Management teams, please feel free to use the numbers located on the bottom right side of the screen and let them know that you would like our member to be assessed.

This slide details some additional resources available to our members and network providers. Listed are important phone numbers, emails, websites for members and provider assistance.

And here are some additional resources for providers that can also be found on the Horizon NJ Health website.

And this concludes our presentation once again we thank you for your participation and look forward for you, joining us in future HEDIS trainings. If you have any additional questions, please contact us at Thank you and have a great day.