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provider hedis

prvdr_hedis_scr
provider·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A provider-level performance rate or composite score derived from Healthcare Effectiveness Data and Information Set measures, reflecting the proportion of eligible patients who received recommended clinical services within the measurement year. HEDIS measures are developed by NCQA and cover preventive care, chronic disease management, behavioral health, and member experience domains. Provider-level HEDIS rates require minimum denominator sizes for statistical reliability and are used in pay-for-performance programs, network tiering, and clinical quality improvement initiatives.

Calculating provider-level HEDIS rates requires hybrid methodology combining claims data with medical record review for measures where administrative data alone is insufficient. Healthcare data teams build HEDIS measure calculation engines that identify eligible denominators, capture numerator events from claims and supplemental data, apply NCQA technical specifications, and produce auditable measure rates at the provider, group, and plan levels.

Standard Abbreviation

prvdr_hedis_scr

Category

provider

Production DDL — DIM_PROVIDER

DIM_PROVIDER.sql
CREATE OR REPLACE TABLE DIM_PROVIDER (
    prvdr_key           INTEGER        NOT NULL  -- surrogate key,
    prvdr_npi           VARCHAR(10)              -- NPI number,
    prvdr_tin           VARCHAR(10)              -- tax ID number,
    prvdr_first_nm      VARCHAR(100)             -- first name,
    prvdr_last_nm       VARCHAR(100)             -- last name,
    prvdr_org_nm        VARCHAR(255)             -- organization name,
    prvdr_typ_cd        VARCHAR(20)              -- provider type code,
    prvdr_spclty_cd     VARCHAR(10)              -- specialty code,
    prvdr_tax           VARCHAR(10)              -- taxonomy code,
    prvdr_state_cd      CHAR(2)                  -- state code,
    prvdr_zip_cd        VARCHAR(10)              -- zip code,
    prvdr_ntwk_sts      VARCHAR(10)              -- network status,
    prvdr_accpt_pt_ind  CHAR(1)                  -- accepting patients,
    prvdr_excl_ind      CHAR(1)                  -- exclusion indicator,
    load_dt             TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

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

Why This Term Matters

Provider data management is one of the most operationally complex data domains in healthcare because providers move, merge, and update their credentials continuously. A data engineer who understands provider terminology can build NPI validation, credentialing, and network adequacy pipelines that keep provider directories accurate and prevent claim rejections. Stale or incorrect provider data is a leading cause of prior authorization delays and CMS compliance findings.

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