HEDIS Patient Data

The purpose of system is to oversee the annual data collection and management of the Healthcare Effectiveness Data and Information Set (HEDIS®) Patient Level Detail (PLD) Data Collection for Medicare Advantage (MA) organizations for the Centers for Medicare & Medicaid Services (CMS). The HEDIS PLD data are used in the CMS MA Star Ratings and the MA Quality Bonus Payments program. The HEDIS PLD is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.

To compare health plan performance; data, based on HEDIS measures, is submitted by MA Plans via text files; this data is then validated and, if valid, stored via an automated service. MA Plans are then alerted whether their files were accepted or rejected.

The HEDIS PLD application consists of the following general components which support the collection of performance measures:
1. File-Watcher is a software component for polling, validating, and storing provider-submitted data. The File-Watcher shall run as a polling service, detecting files as they arrive and queueing them for processing. Files shall be processed on a first-come-first-serve basis. The International Business Machines (IBM) Connect:Direct is a file server established to house provider-submitted data files. The Scope Infotech team administers this server and coordinates with the CMS Electronic File Transfer (EFT) to establish Firewall rules before the submission begins. The file server will be a secure server for receiving provider-submitted data files from CMS EFT transmissions. The files will be staged in a designated directory until detected and processed by the File-Watcher polling program.

2. The Database is available for saving provider-submitted data. The following components explains the system work-flow:

CMS EFT, which moves provider-submitted data files from CMS infrastructure to a designated server running IBM Connect: Direct software.

The HEDIS Patient Level Data Web-Portal, which displays processed file results.

The results of the file processing are stored on a CMS Microsoft Azure Government  SQL server as a Service.

3. Web-Portal is a web-based application that is designed to disseminate, at minimum, HEDIS patient-level data submission information, processed file status, and processed file error reports

4. Service-Desk is an application that is designed to collect, and process Technical Assistance Requests received from MA Contracts, their third-party vendors, and other program participants. Service-Desk application includes establishing and maintaining name and contact information for HEDIS PLD POC, including the Medicare contracts for which the POC is responsible. It also provides ad-hoc reports to the CMS who view and download submission reports.

5. Simple Mail Transfer Protocol (SMTP) Relay send emails to the MA Plan to keep them informed on the status of their submitted HEDIS PLD Files. All communications from the HEDIS PLD application are routed through a SMTP relay via the CMS email server.

Submission Documentation:
The system creates and shares content such as documents and resources, and frequently asked questions (FAQs) which are referenced by the MA Plans during the submission process.

• Name
• E-Mail Address
• Phone Numbers
• Date of Birth
• Mailing Address
• Medical Records Number
• Other - Medicare Beneficiary Identifier (MBI), sex

OMB Control Number: 0938-1028

Expiration Date: 07/31/2024

• Other Federal Agency/Agencies: The HEDIS PLD data is not directly accessible by users of the system. The Patient level data is extracted into an export and is securely transmitted to external federal agencies and private research institutions with appropriate Data user Agreements (DUA) with CMS. Federal agencies include the Veteran Affairs and the Chronic Conditions Warehouse (CCW).
• Private Sector: The HEDIS PLD data is not directly accessible by users of the system. The Patient level data is extracted into an export and is securely transmitted to external federal agencies and private research institutions with appropriate Data user Agreements (DUA) with CMS.

• Administrators: Users with administrator role have access to the name, phone number and email addresses of the MA Plan users to support issues during the submission period and to add secondary Point of Contact (POCs)
• Contractors: The contractors are direct CMS contractors and provide system operations, maintenance, and Help Desk support services for the application.
• Others: MA Plan Primary and Secondary Point of Contact (POC's) who have access to the system can see their own First name and Last name as part of their login.

Annually, prior to the HEDIS PLD data submission, a Submission Instructions Document is uploaded to CMS.gov and the HEDIS PLD Web-Portal. This document provides detailed instructions to the user about the use of the application and data submission.

General Records Schedule (GRS): DAA-0440-2012-0009 / 0001

  DAA-0440-2012-0013 / 0001

  N1-440-09-06 / 2

  N1-440-10-07 / 2/a

  N1-440-10-07 / 2/b

  N1-440-10-07 / 2/c

  N1-440-10-07 / 2/d

Disposition Authority: DAA-0440-2015-0007-0001

Record Schedule Number: DAA-0440-2015-0007

The data retention process and guidelines will follow Records Management Schedule Bucket 5 - Beneficiary Records. The cutoff is at the end of calendar year. The data will be retained for 10 years after cutoff.

The administrative controls in place to secure the PII include access control. The user authentication is provided by CMS Okta Identity Management (IDM). The user will register in IDM for a user account and use the IDM credentials to login to the HEDIS PLD application. The Service Desk users (privileged users) will request the HEDIS PLD SD job code in End User Authentication (EUA) and, upon approval, use their EUA credentials to log into the HEDIS PLD application. After successful authentication, the HEDIS PLD backend middleware performs role-based authorization to verify if the user exists in the database and has the appropriate access to the application. A POC list provided by NCQA will be imported to the database table and while inserting the data, a role will be assigned to the MA contracts user at the beginning of the submission process. For the Service Desk users, an insert script will be created and executed on the database table and a role will be assigned to the user while inserting to the database table.

Encryption: In transit - HEDIS PLD website uses a Secure Sockets Layer (SSL) certificate to encrypt all the data between the user and the website; At rest - Storage disks and Databases are encrypted by Microsoft Azure Government (MAG).

The technical controls in place are firewalls that prevent unauthorized access, encrypted access when users log into the application, and a tiered system architecture which means users can log into the application but not into any test environment. The testing and active applications are not joined together. 

The physical controls in place are addressed by MAG. The HEDIS PLD system is hosted in the MAG (Azure), US-East Region. The data center is in a facility in Northern Virginia.

The HEDIS PLD maintenance team accesses the HEDIS PLD system by CMS authentication and access controls by using security tokens and user credentials.

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