HEDIS® Guidelines and P4P
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 YouthCare accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc.) delivered to its diverse membership.
Use of HEDIS Scores and Calculating HEDIS Rates
HEDIS rates can be calculated in two ways, with administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Hybrid data consists of 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 or encounter data. Therefore, accurate and timely claim and encounter data reduces the necessity of medical record review.
Pay for Performance Program
The YouthCare Pay for Performance (P4P) Program rewards its contracted partners in care for delivering quality preventive healthcare services such as children’s and adolescent’s immunizations, well-child visits, and weight assessments. We listened to your opinions and have added an additional, lower target (the 50th percentile) for 2025.
Incentives are paid after completion of all qualifying services in compliance with HEDIS 2025 guidelines. A complete list of covered codes can be found within the HEDIS Quick Reference Guide 2025 (PDF) .
HIPAA
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 Health Plan and/or vendor will have a signed HIPAA compliant Business Associate Agreement (BAA).