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Quality Measures Track Treatment and Follow-Up Visits for Substance Use Disorders
March 4, 2026
Providers can play an important role in our members’ care by discussing the signs of substance use disorder and encouraging them to seek help, if appropriate. We have information for members that may help.
To monitor our members’ care, we track the following Healthcare Effectiveness Data and Information Set (HEDIS®) measures related to substance use disorders:
Initiation and Engagement of SUD Treatment
This measure applies to members ages 13 and older with a new episode of SUD. We capture two stages of adequate and timely follow-up treatment:
- Initiation of SUD treatment: One treatment visit within 14 days of the diagnosis
- Engagement of SUD treatment: Two or more additional treatment visits within 34 days of the initiation visit
Treatment may occur in an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth or medication-assisted treatment.
Follow-up after Emergency Department Visit for Substance Use
This measure captures ED visits for members ages 13 and older with a principal diagnosis of SUD, or any diagnosis of drug overdose, who had a follow-up visit for SUD. We track:
- ED visits for which the member received follow-up within 30 days (31 total days)
- ED visits for which the member received follow-up within seven days (eight total days)
Follow-Up after High-Intensity Care for Substance Use Disorder
This measure tracks the percentage of discharges for members ages 13 and older who were hospitalized, received detoxification or residential treatment for a diagnosis of SUD and who had a follow-up visit or service for SUD. The follow-up visit must be on a different date than the discharge date. We track:
- Discharges that had a follow-up visit within 30 days after discharge
- Discharges that had a follow-up visit within seven days after discharge
Pharmacotherapy for Opioid Use Disorder
We capture the percentage of new pharmacotherapy treatment events for OUD among our members 16 and older with a diagnosis of OUD. The treatment of OUD with medication must continue for at least 180 days.
Use of Opioids from Multiple Providers
We capture the percentage of our members, 18 years and older, receiving prescription opioids for 15 or more days during the measurement year, who received opioids from multiple providers. We track:
- The percentage of members receiving prescriptions for opioids from four or more prescribers in the year
- The percentage of members receiving prescriptions for opioids from four or more different pharmacies in the year
- The percentage of members receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year
Tips to consider
- Discuss the importance of timely follow-up visits with our members.
Use the same diagnosis for substance use at each follow-up.
- Coordinate care between behavioral health and primary care providers. Share progress notes and include the diagnosis for substance use.
- Reach out to members who cancel appointments and help them reschedule as soon as possible. Watch a video on talking with members about opioid risks and recovery from opioid use disorder.
HEDIS is a registered trademark of the National Committee for Quality Assurance.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their member contract or member guide for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.