Hedis Measure Specification

Overview

Structured interpretation of Healthcare Effectiveness Data and Information Set (HEDIS) quality measures: denominator and numerator logic, continuous enrollment evaluation, exclusion application, National Committee for Quality Assurance (NCQA) audit readiness, and Star Rating-weighted care gap prioritization. Use it when reading measure specifications, evaluating enrollment or exclusions, calculating rates, or prioritizing outreach. The domain tables and decision trees live in the reference files named in , based on NCQA HEDIS Technical Specifications MY 2024.

Workflow

<Workflow - Interpret HEDIS Measure Logic description="Classify a HEDIS reasoning request, load the matching reference, apply the logic, and present a justified result." tools=[get_current_time, file_read] triggers=["User asks to interpret a HEDIS measure", "User asks to evaluate continuous enrollment", "User asks to apply exclusions", "User asks to check NCQA audit readiness", "User asks to calculate a measure rate", "User asks to prioritize care gaps"]

1. [Agent] Establish the measurement year. If the user stated it, use it. Otherwise call get_current_time and infer the most likely reporting year. Validate: A specific measurement year is fixed. If fails: [Ask user] Which measurement year applies?

2. [Decide] Classify the request into exactly one task and select its reference from :

   • Measure structure, components, or rate formula -> references/measure-structure.md
   • Continuous enrollment or allowable gap -> references/continuous-enrollment.md
   • Exclusion application -> references/exclusion-logic.md
   • NCQA audit readiness or data sourcing -> references/audit-requirements.md
   • Care gap prioritization or rate-to-Star interpretation -> references/care-gap-prioritization.md Validate: Exactly one task and reference chosen. If fails: [Ask user] Ask which of these the request concerns.

3. [Agent] Read the selected reference file (and references/measure-structure.md as well whenever a rate is being computed) via file_read. Validate: File content loaded and non-empty. If fails: Report the missing reference path and stop.

4. [Decide] Are the inputs the reference needs present (measure name, member data, enrollment dates, diagnosis codes, current rate, or percentile)? Validate: All inputs required for the chosen task are available. If fails: [Ask user] Request the specific missing inputs.

5. [Agent] Apply the reference logic internally per Rule 7. For rates, compute Numerator divided by (Denominator minus Exclusions). Validate: A conclusion is reached that is consistent with the reference and does not violate Rules 4, 5, or 6. If fails: Re-read the reference and recheck the denominator, gap, and age logic.

6. [Decide] Is any escalation condition met: exclusion logic drops the denominator by more than 10 percent, the result feeds a submission affecting reimbursement or accreditation, or supplemental data shifts a rate by more than 5 percentage points?

   • Yes -> flag the condition and advise validation by a qualified NCQA-certified HEDIS Compliance Auditor before use.
   • No -> continue.

7. [Agent] Present the final result: the specification, rate, enrollment determination, exclusion set, or care gap priority, with a short justification, the stated measurement year, and the Rule 2 disclaimer. Validate: Output states the conclusion, its justification, the measurement year, and the disclaimer. If fails: Add whichever element is missing.

</Workflow - Interpret HEDIS Measure Logic>

• references/measure-structure.md: measure components, rate formula, and the five measure types.
• references/continuous-enrollment.md: measurement year, anchor date, 45-day allowable gap, and the enrollment decision tree.
• references/exclusion-logic.md: exclusion categories and the evaluation order.
• references/audit-requirements.md: NCQA data source hierarchy and common audit findings.
• references/care-gap-prioritization.md: the prioritization decision tree and rate-to-Star interpretation.