HRSN Screening Tools

Updated October 2026

HRSN Screening

HRSN Screening Tools in 2026: What’s Still Required and How to Document It

Federal SDOH screening mandates shifted in 2025. Here’s what’s actually active today and how systematic HRSN screening still protects your quality metrics, contracts, and community outcomes.

SDOH Solutions · October 2026 · 5 min read

Important Update

In 2025, CMS removed several previously proposed SDOH screening mandates, including hospital inpatient/outpatient requirements, MSSP Quality ID 487, and Medicaid HRSN 1115 waiver guidance. This page reflects what remains in force as of October 2026. Meaningful requirements still apply to health plans, FQHCs, hospitals, and provider organizations.

What’s Still Required in 2026

The regulatory picture changed, but the obligation to identify and address social needs didn’t disappear. Active requirements now come through several distinct channels depending on your organization type.

Health Plans

NCQA HEDIS SNS-E

Screen members for food insecurity, housing instability, and transportation barriers, and document a follow-up intervention within 30 days. Requires ECDS/LOINC-coded data submission.

Providers / ACOs

Medicare Community Health Integration (CHI)

CMS now reimburses providers for addressing “upstream drivers of health.” CHI billing requires documented time, the identified driver, and who delivered the service.

FQHCs

HRSA Uniform Data System (UDS)

FQHCs must report SDOH screening data at the ZIP-code level as part of annual UDS submissions, making structured, exportable data a practical necessity.

Texas MCOs

Texas HB 1575 & HB 26

Texas law requires Medicaid managed care organizations to screen pregnant members for social needs (HB 1575) and includes nutrition-related ILOS requirements (HB 26).

Hospitals

Joint Commission NPSG.16.01.01 EP2

Accredited hospitals must screen patients for social needs and connect them with community resources, a standard that remains unchanged.

The Operational Reality

Most care teams are managing HRSN workflows across spreadsheets, paper forms, and disconnected EHR fields. That creates gaps that compound quickly:

!	No consistent way to confirm whether a screened patient received a follow-up intervention, which directly affects HEDIS SNS-E compliance.
!	No visibility into which zip codes or communities have the highest concentration of unmet social needs, making it difficult to direct resources or support UDS reporting.
!	Care coordinators spending time logging referrals manually rather than following up with members who need the most support.
!	CBO referrals sent but never confirmed as completed, with no audit trail when accreditors or plan auditors ask for documentation.
!	CHI service time and upstream driver documentation scattered across notes, lacking the structure CMS billing requires.

How SDOH Solutions Supports HRSN Workflows

SDOH Solutions is a cloud-based platform built to help health plans, FQHCs, and provider organizations manage HRSN screening, referral, and reporting in one place, with structured data that satisfies what auditors and reporting standards actually ask for.

Structured Screening	Conduct screenings using standardized tools including PRAPARE and the AHC Screening Tool. Responses are captured in a structured format aligned with LOINC codes and ICD-10 Z-codes, not just free text.
Community-Level Mapping	Visualize social need prevalence at the FIPS-code level to see which communities and zip codes need which resources, supporting HRSA UDS reporting and resource allocation decisions.
Closed-Loop Referrals	Connect members to community resources and track whether referrals are accepted and completed. This closed-loop workflow supports the 30-day intervention documentation HEDIS SNS-E requires.
Care Coordinator Workflows	Assign tasks, log interactions, and manage member follow-up without toggling between systems. CHI service time and upstream driver documentation are captured as part of the workflow.
Compliance Reporting	Generate reports for HEDIS, UDS, board presentations, and grant requirements, without rebuilding data exports manually each time. Texas MCO and NMDOH reporting contexts are also supported.

Who Uses SDOH Solutions

Health plans and Medicaid MCOs: HEDIS SNS-E member screening and Texas NMDOH requirements under HB 1575 and HB 26.

FQHCs: ZIP- and tract-level data for UDS reporting, CHW workflows, and grant documentation with named screener instruments.

Clinics and provider organizations: Community Health Integration service documentation and care coordination for ACO and value-based care goals.

Care management teams: Social need intervention tracking across large member panels, with referral confirmation and follow-up task management built in.

See It in Action

If your team is navigating HEDIS SNS-E, CHI documentation, UDS reporting, or Texas Medicaid requirements, we’d be glad to walk you through how SDOH Solutions handles it.

Request a Free Demo

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