HEDIS Tech Specs: Is your data ready for MY 2027?

In August, the National Committee for Quality Assurance (NCQA) released the HEDIS^® Measurement Year (MY) 2027 Volume 2 Technical Specifications. With MY 2026 preparation still underway, it's tempting for health plans to wait to fully digest the impact of these changes—but several of them depend on data that takes months to find, map, and validate.

Here are four major considerations for health plans to get started on now.

Person-centered outcome (PCO) measures set a new data standard

Three new Electronic Clinical Data Systems (ECDS) measures apply to Medicare chronic condition special needs plans (C-SNPs) and dual eligible special needs plans (D-SNPs):

• Goal Identification (GID-E): Set a person-centered outcome goal.

• Goal Follow-Up (GIF-E): Set a person-centered outcome goal and followed up on the goal.

• Goal Achievement (GIA-E): Set a person-centered outcome goal and achieved the goal.

Compliance hinges on data many health plans don't capture in structured form: Goal Attainment Scaling (GAS) or Patient-Reported Outcome Measure (PROM) goals, a documented goal domain, and a care plan recorded within seven days of the goal. GAS goals will need to have documentation of follow-up scores from both the practitioner and the patient or caregiver on the same day to count for follow-up or achievement, and PROM goals for follow-up will need to utilize the same PROM instrument LOINC, with available t-scores to identify if meaningful change has occurred for goal achievement.

Additionally, Cotiviti confirmed with NCQA that members who are initially enrolled in other product lines or non-SNP products that later transition to a C-SNP/D-SNP would still be eligible for reporting in the PCO measures, as long as their combined enrollment meets the continuous enrollment timeframe and they are enrolled in a C-SNP or D-SNP on the last day of the measurement year.

Three more new measures, three different data challenges

NCQA finalized three other new measures for MY 2027, and each one brings a different data challenge: expanded code requirements along with a new code system, miscarriage inclusion in a perinatal measure with non-standard denominator exclusions, and utilization tracking for internal evaluation purposes.

• Follow-up After Positive Colorectal Cancer Non-Invasive Screening Test (COF-E): This measure evaluates the percentage of persons aged 45–75 who received a colonoscopy after a positive colorectal cancer non-invasive screening test. It requires positive stool-based test results (LOINC plus a SNOMED result qualifier) for the initial population and a new code system, HL7 ActCode, to exclude tests taken during inpatient, observation, or emergency department (ED) stays. Capturing these results and new codes will likely mean mapping unstructured or new EHR data.
• Prenatal Syphilis Screening (PSY-E): This measure evaluates the percentage of deliveries that had a syphilis screening during the first trimester or within 14 days of the first pregnancy diagnosis or prenatal visit or within 30 days of enrollment in the organization. NCQA dropped the proposed follow-up component that was included in the draft specification shared during its public comment period. This delivery measure uniquely includes miscarriages at 14 or more weeks of gestation. Also unlike NCQA's other delivery measures, it has no deceased exclusion for the pregnant person, and the hospice and palliative care exclusions utilize an expanded two-year timeframe of the measurement year and year prior.
• Continuous Glucose Monitoring for Patients With Diabetes (CGM-E): This measure captures the percentage of persons ages 18–75 with diabetes on insulin therapy who have evidence of continuous glucose monitoring (CGM) in the measurement year. NCQA notes that this measure is intended for internal plan informational purposes only. For persons diagnosed with Type 1 diabetes or evidence of insulin dispensed, CGM utilization can be identified from LOINC, HCPCS, CPT, SNOMED, RxNorm, and NDC codes.

NCQA also released an ECDS version of Glycemic Status Assessment (GSD-E). Both hybrid and ECDS versions are reportable in 2027, with ECDS-only reporting expected for MY 2029. Because GSD-E can use supplemental data to identify eligible members, the initial population is likely to be larger than the administrative GSD measure.

Specialty, billing, and definition changes will move rates

NCQA is changing how provider specialties are utilized across several measures. Additionally, updates to maternity billing standards and race and ethnicity data capture will impact measures in 2027. The edits look small in the specs, but they can change who counts toward compliance, so rates may shift even when care delivery doesn't.

• Follow-up After Hospitalization for Mental Illness (FUH) and Follow-Up After Emergency Department Visit for Substance Use (FUA) will no longer utilize mental health provider specialty to identify compliant follow-up visits. Compliance now requires a mental health diagnosis on the claim, which narrows the paths to compliance for FUH and changes the approach to compliance evaluation for FUA.
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) and Child and Adolescent Well-Care Visits (WCV) will now only evaluate events with primary care practitioners (PCPs). Ensure your qualifying OB/GYNs are mapped to PCP specialties so those visits continue to be utilized for the well care visit measures.
• Care for Older Adults (COA) and Transitions of Care (TRC) will now accept medication reviews from any pharmacist, not only clinical pharmacists—evaluate your specialty mappings to capture this expansion of eligible practitioners.
• Upcoming changes anticipated for maternity care billing standards in 2027 will impact the Prenatal and Postpartum Care (PPC) measure, incorporating CPT codes with a TH modifier as a new method to satisfy both prenatal and postpartum visit compliance—per NCQA FAQs, additional PPC value set changes are also anticipated for the MY 2027 HEDIS Technical Update in March 2027.
• What may appear to be a simple renaming of the race and ethnicity stratification (RES) category of “Asked but No Answer” to “Asked but Declined” could be a larger data capture and ETL impact than it seems. NCQA now requires separate mapping of members who did not provide a race or ethnicity from members who provided a “declined to answer” response—the previous ASKU code will now bucket into the “Unknown” RES category and be considered under the “No Data” source for RDM measure reporting. Members who selected a “declined” response need to be mapped to the new asked-declined code to prevent them from getting bucketed as Unknown race/ethnicity.

Pending retirements could reshape your programs

NCQA has flagged 10 measures for retirement for the reasons noted below, and is expected to move forward with finalizing the retirement of the following measures:

• Documented Assessment After Mammogram (DBM-E) has limited usefulness due to poor design and lack of data source deduplication.
• Oral Evaluation, Dental Services (OED) and Topical Fluoride for Children (TFC) dental measures are being removed in favor of CMS Core’s more widely used OEV-CH and TFL-CH measures.
• Risk of Continued Opioid Use (COU) and Use of Opioids at High Dosage (HDO) provide limited opportunity for plan differentiation—retiring them would reduce burden by eliminating measures addressing similar aspects of care.
• Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) and Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) have small denominators and digital feasibility concerns. NCQA plans to replace them with a more comprehensive serious mental illness measure.
• Diagnosed Mental Health Disorders (DMH), Diagnosed Substance Use Disorders (DSU), and Language Description of Membership (LDM) descriptive information measures are not actionable for quality improvement, and LDM has digital feasibility concerns.

If plans have any internal programs, provider incentives, or value-based care contracts that rely on any of these measures, start planning alternatives for 2027.

Key next steps from Cotiviti

Consider the following short- and long-term steps in your planning as you work through these changes.

• Next 30 days: Review the MY 2027 specs, value sets, and medication lists, and inventory internal programs tied to measures that are expected to retire.
• 30–90 days: Assess data gaps for CGM, syphilis screening, person-centered goals and care plans, maternity CPT codes with TH modifiers, pharmacist specialties, and mental health diagnoses on follow-up claims.
• 90–365 days: Map unstructured data (colorectal cancer screening results, GAS and PROM scores, ActCodes), update race and ethnicity ETL for members with declined responses, and validate OB/GYN-to-PCP specialty mappings.

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