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hedis rate

hedis_rt_pct
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The calculated performance percentage for a specific HEDIS measure representing the proportion of eligible members who received the recommended clinical service or achieved the specified health outcome during the measurement year. HEDIS rates are calculated by dividing the number of members who met the numerator criteria by the number of eligible members in the denominator after applying all specified exclusion criteria. Higher HEDIS rates generally indicate better quality performance, though some HEDIS measures are inverse rates where lower rates indicate better performance such as avoidance of antibiotic overuse or emergency department utilization.

HEDIS rates feed directly into CMS Star Ratings calculations, NCQA health plan accreditation scores, and value based payment performance assessments. Healthcare data teams calculate hedis_rt_pct for each applicable measure using NCQA technical specifications, track rate trends over multiple measurement years, benchmark against national and regional plan distributions, and project year-end rates from partial-year data to guide in-year quality improvement prioritization.

Standard Abbreviation

hedis_rt_pct

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
    qlty_key        INTEGER        NOT NULL  -- surrogate key,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    plan_key        INTEGER        NOT NULL  -- FK to DIM_PLAN,
    meas_yr         SMALLINT                 -- measurement year,
    hedis_meas_cd   VARCHAR(20)              -- HEDIS measure code,
    denom_ind       CHAR(1)                  -- denominator eligible,
    numer_ind       CHAR(1)                  -- numerator met,
    excl_ind        CHAR(1)                  -- exclusion indicator,
    gap_open_ind    CHAR(1)                  -- care gap open,
    star_rtg_nbr    DECIMAL(3,1)             -- star rating,
    qlty_scr        DECIMAL(5,2)             -- quality score,
    perf_thrsh_pct  DECIMAL(5,2)             -- performance threshold,
    raf_scr         DECIMAL(10,3)            -- risk adjustment factor,
    outreach_cnt    SMALLINT                 -- outreach attempts,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →

Why This Term Matters

Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.

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