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HEDIS Measure Conformance Specifications

Status: Draft (2026-05-18) — aligns with NCQA HEDIS MY 2026 Technical Specifications. Owners: CL core (clinical reporting), PF-70 (terminology / value sets). Scope: Documents how Encore implements the four HEDIS measures surfaced by CL-15 / CL-35: Lightweight aggregates surfaced by useReportRuns / computeQmSummary are not NCQA-conformant numerators; they exist only to populate the CL-15 portal QM dashboard. Conformant numerators MUST come from the calculators referenced above.

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Value-set sourcing (PF-70)

All HEDIS code lists are sourced from the PF-70 terminology library — never hardcoded: Value-set refresh cadence and provenance live in docs/pf/pf-70-terminology-admin-guide.md. Tenants MUST NOT override these value sets — overrides go through PF-15 picklists in non-HEDIS contexts only.

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FUH — Follow-Up After Hospitalization for Mental Illness

Owner: CL-29-EN-65 (cl-fuh-calculator edge function). Documented here for cross-reference only — no recomputation in this codebase.
  • Eligible population: Members ≥ 6 years discharged from an acute inpatient stay with a principal mental-illness diagnosis (HEDIS_MH_PRINCIPAL).
  • Denominator: Eligible discharges in the measurement year. Multiple discharges per member counted separately per NCQA spec.
  • Numerator (30-day): Follow-up visit with a mental-health practitioner within 30 days of discharge (HEDIS_FOLLOWUP_VISIT).
  • Numerator (7-day): Same but within 7 days.
  • Exclusions: Death during measurement period; discharges followed by readmission ≤ 30 days; member with non-acute inpatient stay during the follow-up window.
  • Reporting stratification: Total, 6–17, 18–64, 65+.

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FUM — Follow-Up After ED Visit for Mental Illness

Owner: CL-29-EN-65.
  • Eligible population: Members ≥ 6 years with ED visits where the principal diagnosis is a mental-illness condition.
  • Denominator: Eligible ED visits in measurement year (no follow-up admission within ≤ 24 hours).
  • Numerator (30-day / 7-day): Follow-up encounter with a mental-health provider within the window.
  • Exclusions: ED visits resulting in inpatient admission; death during measurement period.

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IET — Initiation and Engagement of SUD Treatment

Owner: CL-35, src/cores/cl/utils/hedisCalculation.ts.
  • Denominator (isInIetDenominator): Members with a new SUD episode (HEDIS_SUD) — no SUD claim in the 60 days prior (negative-history window).
  • Initiation numerator: Initiation visit (HEDIS_SUD_VISIT) within 14 days of the index event. Constant: IET_INITIATION_WINDOW_DAYS = 14.
  • Engagement numerator (isInIetNumerator): Initiation met AND ≥ 2 additional SUD visits within 34 days of the initiation visit. Constants: IET_ENGAGEMENT_WINDOW_DAYS = 34, IET_ENGAGEMENT_MIN_VISITS = 2.
  • Exclusions: Hospice; death; SUD claim in the 60-day negative-history window.

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AMM — Antidepressant Medication Management

Owner: CL-35, src/cores/cl/utils/hedisCalculation.ts.
  • Denominator (isInAmmDenominator): Members ≥ 18 with major depression dx + at least one antidepressant dispensing event in the measurement period.
  • Acute-phase numerator (isInAmmNumerator(_, 'acute')): ≥ 84 days of antidepressant medication coverage (AMM_ACUTE_MIN_DAYS).
  • Continuation-phase numerator (isInAmmNumerator(_, 'continuation')): ≥ 180 days of antidepressant coverage (AMM_CONTINUATION_MIN_DAYS).
  • Exclusions: Bipolar / psychosis diagnoses; hospice; death; pharmacotherapy gaps > 30 days within the measurement window (handled in calculator query — not in the pure function).

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Rate calculation

All rates use calculateMeasureRate(denominator, numerator) which returns a NUMERIC(5,4) value in [0.0000, 1.0000]. Zero-denominator measures return 0.0000 and are flagged in the UI as “insufficient data” — never as 0% performance.

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Verification & conformance

  • Unit-test coverage: src/cores/cl/utils/__tests__/hedisCalculation.test.ts (AMM, IET denominator/numerator + rate clamping).
  • Cross-reference: NCQA HEDIS MY 2026 Volume 2 (Technical Specifications). Each measure section above maps 1:1 to NCQA chapter headings; deviations require an ADR.
  • Audit trail: every HEDIS report run is logged to pf_audit_logs via logClinicalAudit({action: 'cl_clinical_audit_report_run'}) per CL-15 T-COMP-3.

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Known gaps (tracked)

  1. FUH/FUM 30-day exclusion for non-acute inpatient overlap is implemented in the edge function only — no pure-function port yet (CL-29 follow-up).
  2. AMM continuous-enrollment gap rule (≤ 45-day gap) is enforced in the SQL query, not in isInAmmNumerator. Refactor planned with CL-15-EN-NN.
  3. PF-70 value-set version pinning per measurement year is pending PF-70-EN-04.
Last Updated: 2026-05-18 (CL-15 T-COMP-2).