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Healthcare Effectiveness Data and Information Set (HEDIS)

Employers and individuals use HEDIS to measure the quality of health plans. It measures how well health plans give service and care to their members. The data from these measures are reported to the National Committee for Quality Assurance (NCQA), which rates health plans based on more than 90 measures across six areas of care.

The 6 HEDIS Measure Categories:

  • Effectiveness of Care
  • Access/Availability of Care
  • Experience of Care
  • Utilization and Risk Adjusted Utilization
  • Health Plan Descriptive Information
  • Measures Reported Using Electronic Clinical Data Systems

During this time, we will be reaching out to request medical charts. We appreciate any assistance you can provide in the collection of this data.

If you have questions or are interested in options to assist with record retrieval please contact our Quality department at BuckeyeQualityImprovement@CENTENE.COM.

Quality/HEDIS Focus: Breast Cancer Screening

October is Breast Cancer Awareness Month. According to the National Breast Cancer Foundation, “One and Eight Women in the United States will develop breast cancer in her lifetime.”  Breast self-exam (monthly), regular clinical breast exam and mammograms are key to early detection and survival. The recommendation for women age 40 and older is to have a mammogram every one or two years, even if they have no symptoms and/or risk of breast cancer. Early detection is key!

HEDIS Measurement and Coding

Breast Cancer Screening Measure:  Women ages 50-74 must have completed a mammogram to screen for breast cancer at least every 2 years.  (Note: Breast MRI, Breast Ultrasound and biopsies do not count as a screening for breast cancer.)

CPT Codes: 77055 – 77057, 77061 – 77063, 77065 – 77067

HCPCS codes: G0202, G0204, G0206

Please encourage all women age 40 and older to get their Mammogram!  Member incentive may apply to some Buckeye members.  

HEDIS Measure Deep Dive: Appropriate Treatment for Upper Respiratory Infection

The Appropriate Treatment for Upper Respiratory Infection measure, or URI, is a metric derived from the percentage of members (three months and older) with a diagnosis of upper respiratory infection that did not result in an antibiotic event. Typically, antibiotics are not recommended for upper respiratory infection, as these are usually viral in nature. Research has shown that the use of antibiotics for diagnoses for which it is not appropriate or warranted, such as upper respiratory infection, is not only ineffective in reducing complications, but also increases medical costs by inducing side effects and resistance to antibiotics (Yoon et al., 2017 – view this .gov resource here). This measure is therefore inverted, meaning the less antibiotics providers prescribe in response to upper respiratory infections, the better.

To close the gap and thus improve HEDIS scores, this measure relies on provider prescribing practices to reflect an avoidance of antibiotic prescriptions in response to upper respiratory infection on or three days after the day of diagnosis.


  • Providers are encouraged to educate members, parents, and caregivers on alternative remedies to antibiotics such as acetaminophen for fever, over the counter medicine for cough and inflammation, and rest and extra fluids for treatment.
  • Per the CDC, it is encouraged that providers promote appropriate antibiotic use to avoid antibiotic resistance. The CDC website has some very useful handouts for both patients and providers that talk about appropriate antibiotic use and includes resources such as specific antibiotic aware prescription pads for provider use.