HEDIS MY2025 Audit Changes
November 13, 2025
Aside from the usual updates to the audit timeline and other wording changes, this year’s HEDIS audit manual includes several changes of significance.
1. Medical record review (MRR) Validation:
If your organization is using technology-driven abstraction processes (e.g., artificial intelligence (AI)) this year, prepare your team for some additional audit requirements.
- HEDIS MY2025 Roadmap – Answer the new questions regarding where and how technology is implemented for medical record review abstraction.
- MRR System/Process Review – Be prepared to provide a demonstration of any new automated technology used for MRR abstraction.
- Program Oversight – Report quality and accuracy standard results for automated abstraction technology separately from manual MRR abstraction.
- Convenience Sample Validation – If this is the first year your organization is implementing automated technology for MRR, expect that convenience sample validation will be required.
- MRR Hybrid Counts – Ensure your MRR software can identify and report on numerator and exclusion hits from manual-driven and technology-driven abstraction processes separately.
- Final Statistical Validation – Be prepared to undergo final validation separately for numerators and exclusions hits from manual-driven v. technology-driven abstraction processes.
2. Supplemental Data Validation:
If your organization is considering including any new supplemental data sources for HEDIS MY2025, be prepared to undergo primary source verification (PSV) for all first-year nonstandard supplemental files, first-year files using the C-CDA or FHIR data standards, and any files where AI or machine learning are involved.
As HEDIS expectations evolve—particularly around AI, technology-driven abstraction, and supplemental data validation—having the right partner matters.
Advent brings hands-on audit expertise to help you prepare, validate, and operationalize these new requirements.
Let’s work together to strengthen your audit readiness for MY2025. Contact Advent to get started.
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Advent’s HEDIS 2026 webinar series kicked off last month with Optimizing Clinical Data Quality, a presentation focused on common challenges with supplemental clinical data. Key takeaways include the following: Transition in Data Collection: The shift from manual data collection to digital HEDIS reporting has increased the focus on clinical data over claims data. NCQA’s planned elimination of the hybrid reporting method has added urgency to this transition, driving plans to acquire more electronic clinical data and adapt to year-round ingestion. Challenges with Clinical Data: The presentation highlighted several challenges to the acquisition of supplemental clinical data, including data timing, completeness, and accuracy. Issues such as short turnaround times, missing biometric values, and incorrect coding have impacted the useability of these additional data sources for HEDIS reporting. Tips for Navigating the Transition: Plans can navigate this transition by starting early with clinical data validation, engaging with IT departments, exploring vendor’s reports and supportive capabilities, and building executive leadership buy-in.
Another year of Medicare Part C and Part D Data Validation (DV) audits is in the books. Here are a few key takeaways and best practices from this year’s experience: 1. Share CMS Technical Specifications Early Ensure all report owners receive CMS technical specs and reporting requirements well in advance. This promotes clear understanding of required data elements and ensures alignment for HPMS submissions and audit readiness. 2. Strengthen Internal Quality Control A robust internal QC process is essential. Assign a lead to manage this effort and establish standardized checks. Block time in March to confirm that what’s submitted in HPMS accurately reflects your intended data. 3. Validate Vendor Data Throughout the Year Accurate reporting hinges on reliable vendor data. Set expectations for vendors with delegated reporting responsibilities to provide both summary and detailed data. Request clear references or documentation to interpret results effectively. 4. Create a Centralized Measure Reporting Library Maintain a central repository that includes final submissions (HPMS summary and supporting detail), measure logic, and relevant policies and procedures. These documents not only support measure reporting but also fulfill many DV audit documentation requirements. Congratulations to our Medicare clients on another successful reporting year. As always, early preparation and strong processes are the foundation of accurate reporting and DV audit success.
With the ink barely dry on HEDIS MY2024, planning for HEDIS MY2025 is already underway. Advent’s HEDIS webinar series will start up soon. In the meantime, here are some changes to keep in mind.
Earlier this month, Advent met with NCQA to confirm their plan to provide the HEDIS measure specifications in a digital format. Key takeaways from the meeting are outlined below. NCQA’s Digital Content Services use FHIR® data only. Users must secure data in or convert data to a FHIR format to execute NCQA’s digital quality measures (dQMs). A parallel testing plan will be implemented to compare measures produced using traditional certified measure code to those executed using NCQA’s digital measure packages. Plans may elect to use NCQA’s Digital Content Services directly. However, they will likely still need a vendor, or internal resources, for other reporting functions, including producing patient-level detail files and XMLs for loading the IDSS as well as medical record review tools. As measure certified vendors move to using NCQA’s digital packages for their measure logic, measure certification will change to dQM Implementation Validation. The dQM Implementation Validation program will confirm “correct execution of the digital content in the organization's environment” to ensure the digital quality measures execute as expected. NCQA plans to move to a fully digital state by MY 2030. This aligns with their goal to completely phase out the hybrid method by MY 2029. For more information, check out NCQA’s recent webinar on Digital Quality Transition Update: May 2025 - NCQA . FHIR® is a registered trademark of Health Level Seven International and its use does not constitute endorsement by HL 7.
