Download Commercial, QUEST, Akamai Advantage Primary Care

2016 Commercial,
QUEST Integration, and
HMSA Akamai Advantage
Primary Care
January 2016
(Released December 2015)
Pay for
Quality
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Table of Contents
Introduction to the 2016 Primary Care Pay-for-Quality Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Program Eligibility and Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Program Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Target Dates & Deliverables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Scoring Period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Cozeva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Pay-for-Quality Data Sources and Supplemental Data Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Inquiry and Request for Reconsideration of Pay-for-Quality Award Payment and Methodology. . . . . . . . . . . . . . . . . 8
Pay-for-Quality Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Preventive Health Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Childhood Immunizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Immunizations for Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Heart Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Comprehensive Diabetes Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Appropriate Respiratory Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Chronic Disease Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Patient Population and Member Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Pay-for-Quality Payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Payment Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Quality Payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Payment Philosophy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Commercial Maximum Payment Potential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Commercial Performance Quality Report Example. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Commercial Quality Scoring Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Step 1: Calculation of Maximum Payment for Each Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Step 2: Performance and Improvement Points Earned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Step 3: Calculation of Actual Payment Earned for Each Measure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Threshold Scale Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Performance and Improvement Points by Performance Level Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Quest Integration Maximum Payment Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Quest Integration Performance Quality Report Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Quest Integration Quality Scoring Calculations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Step 1: Calculation of Maximum Payment for Each Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Step 2: Performance and Improvement Points Earned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Step 3: Calculation of Actual Payment Earned for Each Measure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Threshold Scale Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Performance and Improvement Points by Performance Level Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
HMSA Akamai Advantage Maximum Payment Potential. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
HMSA Akamai Advantage Performance Quality Report Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
HMSA Akamai Advantage Quality Scoring Calculations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Step 1: Calculation of Maximum Payment for Each Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Step 2: Performance and Improvement Points Earned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Step 3: Calculation of Actual Payment Earned for Each Measure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
National Stars Threshold Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Performance and Improvement Points by Performance Level Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Step 4: Application of the RCC Adjuster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Appendix A - Pay-for-Quality Measure Detail. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Appendix B - Patient Attribution Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
1
Introduction to the 2016 Primary Care Pay-for-Quality Program
• Weight Assessment and Counseling for Nutrition and
Physical Activity for Children/adolescents
This is a new measure that includes the following assessments
for children and adolescents aged 3-17 years:
Thank you for your dedication to providing high quality care to
HMSA members. Your hard work has improved the quality of
health care and enhanced the patient experience. Together we’ve
made important gains in clinical quality, patient safety, cost
management, and well-being improvement.
– BMI percentile documentation.
In 2016, our P4Q programs will continue focusing on processes
and outcomes that result in high-value primary care for our
members. For your convenience, we’ve consolidated the details
of our pay-for-quality programs, across Commercial, QUEST
Integration, and HMSA Akamai Advantage lines of business,
into a single guide. The following program changes are effective
January 1, 2016.
– Counseling for nutrition.
– Counseling for physical activity.
The following measures were removed from the program:
– Annual Monitoring for patients on ACEI or ARB.
– Annual Monitoring for patients on Diuretics.
Summary of Changes
–A
voidance of Antibiotic Treatment in Adults with
Acute Bronchitis.
COMMERCIAL
– Medication Adherence for Cholesterol (Statins).
• Advance Care Planning
The following codes will be accepted for numerator credit:
1123F, 1124F, 1157F, 1158F, 99497, 99498, S0257.
– Medication Adherence for Hypertension (RAS antagonist).
– Medication Adherence for Oral Diabetes Medications.
• Breast Cancer Screening
Numerator specifications for the Breast Cancer Screening
measure have been changed as follows: Patients who had one
or more mammograms performed during the measurement
period or the 15 months prior to the measurement period.
HMSA AKAMAI ADVANTAGE
• Body Mass Index Assessment
The Body Mass Index (BMI) Assessment measure denominator
will include patients aged 18-74 years.
• Breast Cancer Screening
Numerator specifications for the Breast Cancer Screening
measure have been changed as follows: Patients who had one
or more mammograms performed during the measurement
period or the 15 months prior to the measurement period.
• Advance Care Planning
The following codes will be accepted for numerator credit:
1123F, 1124F, 1157F, 1158F, 99497, 99498, S0257.
• Weight Assessment and Counseling for Nutrition and
Physical Activity for Children/Adolescents
This is a new measure that includes the following assessments
for children and adolescents aged 3-17 years:
• Body Mass Index Assessment
The Body Mass Index (BMI) Assessment measure denominator
will include patients aged 18-74 years.
– BMI percentile documentation.
• Review of Chronic Conditions
The measure will display information from the “Cozeva Coding
Specificity” tool. See “Review of Chronic Conditions” on
page 68 for details.
– Counseling for nutrition.
– Counseling for physical activity.
The following measures were removed from the program:
The following measures were removed from the program:
– Annual Monitoring for patients on ACEI or ARB.
– Comprehensive Diabetes Treatment.
– Annual Monitoring for patients on Diuretics.
– Medication Adherence for Cholesterol (Statins).
– Medication Adherence for Hypertension (RAS antagonist).
– Medication Adherence for Oral Diabetes Medications.
QUEST INTEGRATION
• Breast Cancer Screening
Numerator specifications for the Breast Cancer Screening
measure have been changed as follows: Patients who had one
or more mammograms performed during the measurement
period or the 15 months prior to the measurement period.
• Body Mass Index Assessment
The Body Mass Index (BMI) Assessment measure denominator
will include patients aged 18-74 years.
2
Program Eligibility and Enrollment
Additional Eligibility Criteria
Providers will automatically be enrolled in each 2016 Pay-forQuality Program for which he/she fulfills all eligibility criteria.
Please note that some criteria apply uniquely to Commercial,
QUEST Integration, and HMSA Akamai Advantage pay-for-quality
programs. Note: Exceptions to eligibility criteria may be made at
HMSA's sole discretion.
COMMERCIAL
1. P
articipation in HMSA’S PPO plan at the end of the
measurement period.
2. Additional eligible specialty type: Pediatrics.
Universal Eligibility and
Enrollment Criteria
3. M
ust belong to a Provider Organization (PO) (be participating
in a Patient-Centered Medical Home program).
The following universal eligibility criteria are applied across
Commercial, QUEST Integration, and HMSA Akamai Advantage
pay-for-quality programs:
1. P
articipation in HMSA’S PPO plan at the end of the
measurement period.
QUEST INTEGRATION
2. Additional eligible specialty type: Pediatrics.
1. Practice in one of the following specialties:
HMSA AKAMAI ADVANTAGE
• Family medicine.
1. P
articipation in HMSA Akamai Advantage at the end of the
measurement period.
• General practice.
• Internal medicine.
2. M
ust belong to a PO (be participating in a patient-centered
medical home program).
• Advanced practice registered nurses.
• Physician assistants under the supervision of a pay-for-quality
program-eligible primary care provider.
2. Exclusions
Providers with the aforementioned specialties who are practicing
as hospitalists or emergency care providers are excluded from
the program. In addition, HMSA reserves the right to exclude
other non-primary care specialists in accordance with the
Centers for Medicare & Medicaid Services (CMS) standards.
Enrollment Conditions
Providers must agree to the following:
• Participate fully in the pay-for-quality program and the quality
improvement activities necessary to evaluate their performance
and improvement.
• Accept HMSA’s determination of the pay-for-quality score and
understand that the score will serve as the basis for any payfor-quality award from HMSA. Providers may request reconsideration of their score and/or award, but must follow established
procedures for reconsideration (see Inquiry and Request for
Reconsideration section on page 8).
• Providers, at their sole cost and expense, will maintain
adequate records related to their obligations under the payfor-quality program. Providers agree that the Department of
Health and Human Services, the comptroller general, and/or
their designees will have the right of access and entry to this
information and to providers’ facilities, including computer and
other electronic systems, that pertain to any aspect of
providers’ performance that results in payments from HMSA
for the purposes of audit, evaluation, and/or inspection.1
Required by regulations promulgated under the Affordable Care Act, 45 C.F.R § 158.501.
1
3
Program Summary
Target Dates and Deliverables
As a pay-for-quality initiative, this program translates accepted
evidence-based medicine into standards that can be
objectively measured through analyses of claims and other
verifiable data. Establishing measurable quality standards is a
constantly evolving process as new clinical evidence is
discovered and new treatments are developed.
COMMERCIAL • QUEST INTEGRATION
DATE
Measurement Responsibility
All providers (regardless of specialty) are scored on all measures
for which their patient panels are eligible.
COMMERCIAL & QUEST INTEGRATION
MILESTONES
January 1, 2016
2016 pay-for-quality program begins.
April 2016
First-quarter claims runout.
April 30, 2016
Deadline for supplemental data to be included in
first-quarter performance, payment, and
Requests for Reconsiderations.
May 2016
Processing and scoring.
June 2016
First-quarter performance report and payment.
July 2016
Second-quarter claims runout.
July 31, 2016
Deadline for supplemental data to be included in
second-quarter performance, payment, and
Requests for Reconsiderations.
August 2016
Processing and scoring.
September 2016 Second-quarter performance report and payment.
October 2016
Third-quarter claims runout.
October 31,
2016
Deadline for supplemental data to be included in
third-quarter performance, payment, and
Requests for Reconsiderations.
November 2016
Processing and scoring.
December 2016
Third-quarter performance report and payment.
January 2017
Fourth-quarter claims runout.
January 31,
2017
Deadline for supplemental data to be included in
fourth-quarter performance, payment, and
Requests for Reconsiderations.
February 2017
Processing and scoring.
March 2017
Fourth-quarter performance report and payment.
HMSA AKAMAI ADVANTAGE
DATE
AKAMAI ADVANTAGE MILESTONES
January 1, 2016 2016 pay-for-quality program begins.
4
May 2016
Performance quality report for period ending
March 30, 2016.
August 2016
Performance quality report for period ending
June 30, 2016.
September 30,
2016
End of the measurement period for the review of
chronic conditions (RCC) measure and deadline
for submission of RCC supplemental data.
November 2016
Performance quality report for period ending
September 30, 2016.
January 31,
2017
Deadline for submission of supplemental data for
the staying healthy and managing chronic
conditions measures and Requests for Reconsiderations.
February –
March 2017
Processing and scoring.
April 2017
Annual performance quality report and payment.
Scoring Period
Weight Assessment and
Counseling for Nutrition and
Physical Activity for Children/
Adolescents
COMMERCIAL • QUEST INTEGRATION
SCORING
PERIOD
MEASUREMENT
PERIOD
BASELINE
PERIOD
First quarter
2016
April 1, 2015,
through
March 31, 2016
April 1, 2014,
through
March 31, 2015
Second quarter
2016
July 1, 2015,
through
June 30, 2016
July 1, 2014,
through
June 30, 2015
Third quarter
2016
October 1, 2015,
through
September 30, 2016
October 1, 2014,
through
September 30, 2015
Fourth quarter
2016
January 1, 2016,
through
December 31, 2016
January 1, 2015,
through
December 31, 2015
SCORING PERIOD
MEASUREMENT
PERIOD
BASELINE
PERIOD
Measurement period
for Chronic Disease
Review Measure
(i.e., Review of
Chronic Conditions)
January 1, 2016,
to September 30,
2016
January 1, 2015, to
September 30, 2015
Measurement period
for Staying Healthy
& Managing Chronic
Conditions Measures
(i.e., all other
measures)
January 1, 2016, to
December 31, 2016
January 1, 2015, to
December 31, 2015
First Quarter 2016
January 1, 2016 to March 31,
2016
Second Quarter 2016
January 1, 2016 to June 30,
2016
Third Quarter 2016
January 1, 2016 to September
30, 2016
Fourth Quarter 2016
January 1, 2016 to December
31, 2016
There is no baseline for this measure and no improvements
points will be awarded in 2016.
HMSA AKAMAI ADVANTAGE
SCORING
PERIOD
MEASUREMENT
PERIOD
5
Cozeva
• Care Planning Registry: A platform that you and your care
teams can use to identify patients who may benefit from
additional care as related to pay-for-quality program metrics.
The Care Planning Registry is refreshed every week.
Cozeva is a dynamic population health management tool that lets
providers access their data in a meaningful, actionable, and
supportive manner. HMSA strongly encourages the use of
Cozeva to help you maximize the quality of your care and your
pay-for-quality awards.
• Supplemental Data: Allows you to supplement claims- based
data with information from your clinical records and immediately updates your Care Planning Registry.
The use of Cozeva over time gives you an integrated approach to
managing each of your patient’s chronic conditions and comorbidities. Cozeva allows standards of care delivered by any and
all providers caring for your patient to be reported and monitored
accurately. It provides a care planning registry that identifies gaps
in care in accordance with the best standards of care. You can
track medication adherence by identifying prescriptions filled,
display lab results when available, and add data from the medical
record to demonstrate care in accordance with standards. Your
ability to identify gaps in care and manage visits allows better
engagement with your patients.
Note: Supplemental data that doesn’t have a supporting claim
(shown as “pending” in Cozeva) will be removed after 30 days.
• Member Engagement: Helps you deliver appointment
reminders, alerts, and secure messages to your patients.
• You can also collaborate with your patients’ designated family
members and friends to encourage better health care.
• Performance Quality Report: A report to measure your
performance for each quarter. You can access a detailed view
of each measure, including national percentile target rate and
estimated quality pay by percentile ranking.
These and other tools and reports are described below:
• Patient Panel: A monthly list of patients attributed to you by
HMSA from all lines of business.
6
Pay-for-Quality Data Sources and Supplemental Data Process
Pay-for-Quality Data Sources
Supplemental Data Review:
Methodology for the QI Review
The pay-for-quality program uses claims data as the primary
source to identify patients who meet the numerator and
denominator criteria.
The supplemental data review for measures excluding the review
of chronic conditions measure is conducted by HMSA’s QI unit
twice a year (second and fourth quarters). HMSA applies a
randomized process, selecting 5 percent or 30 entries
(whichever is less) for review (by measure). Requests are then
sent to the PCP to provide medical record documentation that
supports each entry.
Claims data, on occasion, may not be adequate to meet
numerator criteria or identify denominator exclusions.
For example, claims data may indicate that a woman needs a
breast cancer screening when the medical record indicates that
she has had a bilateral mastectomy.
For PCPs who don’t respond to a request for documentation
during the initial review, the selected entries are deleted and
no credit is awarded. For PCPs who are found to have one or
more unsupported entries, such as when the date of service in
the medical record doesn’t match the date of service provided
in the entry, HMSA will conduct a second review to validate the
accuracy of a larger sample of entries for the same measure that
was found to be unsupported. For the second review, 10 percent
or 10 entries (whichever is less) are selected.
As a result, providers are able to submit supplemental data for
certain measures via Cozeva to provide evidence for services that
were rendered in the provider's medical record.
Additionally, a provider can also submit a Request for
Reconsideration to provide evidence that a patient isn't eligible
for a given measure. See page 8 for details.
Supplemental Data Review
If the PCP doesn’t respond to a request in the second review or if
two or more entries are found to be unsupported, all of the PCP’s
entries for that measure are removed and the PCP’s pay-forquality score and payment is adjusted for the scoring period of
these entries.
The pay-for-quality program includes a supplemental data review
to ensure the integrity of the supplemental data that the PCP
submits during the year. The review will select supplemental data
submissions and request medical records to support supplemental data submissions. HMSA’s Quality Improvement (QI) unit will
conduct the supplemental data reviews for measures, excluding
the review of chronic conditions. Supplemental data received for
the review of chronic conditions may be reviewed by HMSA.
As provided for in their participating provider agreement with
HMSA, PCPs or group administrators may submit an inquiry or
request for reconsideration of their pay-for-quality score and/or
award by HMSA.
PCPs are asked to provide any requested medical records by
mail or fax by the date indicated in the request. HMSA won’t pick
up records or perform on-site chart reviews. All self-reported
information must be consistent with the information that was
recorded in the patient’s medical record and must include the
exact service and the date on which the service was performed.
Supplemental Data Review:
Methodology for the RCC Review
HMSA AKAMAI ADVANTAGE (ONLY)
Appendix A identifies the supplemental data submission
opportunities and requirements for each measure.
The supplemental data review for the HMSA Akamai Advantage
review of chronic conditions measure may be conducted by
HMSA annually, following the measure’s deadline for supplemental data.
If conducted, the review will identify supplemental data entries
that cannot be confirmed or denied through research of claims
history, past chart reviews, and other data sources. These
supplemental data entries will be subject to a review of the
supporting medical record documentation that was uploaded
with the supplemental data entry.
Each supplemental data entry that is found to be invalid will be
deleted and the PCP’s pay-for-quality score and payment will be
adjusted for the scoring period in which the entry was submitted.
7
Inquiry and Request for Reconsideration of Pay-for-Quality
Award Payment and Methodology
Inquiries
– Date of service.
– Diagnosis.
An inquiry is defined as a request for additional information about
the pay-for-quality program.
– Lab result.
General inquiries about the pay-for-quality program (not specific
to scores or results) will be answered at any time throughout
the year.
Request for Reconsideration Process
1.Complete one Supplemental Request for Reconsideration form
per patient. The form is on Cozeva.
Send inquiries by:
2.Submit the form to HMSA.
• Letter. Mail to:
Fax: 948-6887 on Oahu
Hawai‘i Medical Service Association
Attn: POA – Rm. 503
P.O. Box 860
Honolulu, HI 96808-0860
Email: [email protected]
Mailing address:
Hawai‘i Medical Service Association
Attn: POA – Rm. 503
P.O. Box 860
Honolulu, HI 96808-0860
• Phone. Please call HMSA.
For assistance identifying your contact, please call 948-6820 on
Oahu or 1 (877) 304-4672 toll-free on the Neighbor Islands.
3.HMSA will review and respond to your request no later than
60 days after receiving your request.
• Web. Use the Contact Us feature on Cozeva.
Requests for Reconsideration
4.If you’re dissatisfied with HMSA’s response to your request
for reconsideration, additional dispute resolution remedies
are available to you under your HMSA participating
provider agreement.
Reconsideration is defined as a request for HMSA to change a
determination it has made regarding a provider’s reported scores
and/or payment.
Questions
• Email. Send to [email protected].
If you have questions, please call 948-6820 on Oahu or
1 (877) 304-4672 toll-free on the Neighbor Islands.
Note: When a particular service is shown as incomplete in the
provider’s Care Planning Registry, Cozeva enables you to submit
supplemental data for some measures to show that the service
was performed. When a situation doesn’t match one of the
Supplemental Data options listed on Cozeva, you may submit
a Supplemental Data Request for Reconsideration. Request for
Reconsideration will only be accepted until after the one-month
run out period (per quarter).
A request for reconsideration submitted within the criteria
explained below should include supporting data, if available.
(A request for reconsideration won’t be accepted verbally.)
Requests for reconsideration must communicate:
• Why the online supplemental data process didn’t enable the
provider to record supplemental data that satisfies denominator exclusion criteria.
• Clinical rationale and supporting citations for denominator
exclusion.
• Measure.
• Patient.
• Medical record information to support denominator exclusion
such as:
– Service/procedure.
8
Pay-for-Quality Clinical Measures
Preventive Health Screening
MEASURE
• •
•••
•••
Advance care planning
HIGH-LEVEL DEFINITION
The percentage of patients 75 years and older at the end of the measurement period who
had an advance care plan and/or an advance care planning discussion with their PCP
documented during the measurement period.
Body mass index
assessment
The percentage of patients 18–74 years of age who had an outpatient visit and whose body
mass index was documented during the measurement period.
Breast cancer screening
The percentage of women 52–74 years of age who had one or more mammograms during
the 27 months prior to the end of the measurement period.
••
Cervical cancer screening
The percentage of women 24–64 years of age who were screened for cervical cancer using
either cervical cytology during the measurement year or the two years prior. If age 30–64,
a cervical cytology and a human papillomavirus (HPV) test with service dates four or less
days apart during the measurement period or the four prior measurement periods are
also accepted.
••
Chlamydia screening for
women
•••
••
••
••
The percentage of women 16–24 years of age who were identified as sexually active and
who had at least one test for chlamydia during the current measurement period.
(USPSTF guideline)
Colorectal cancer
screening
The percentage of patients 51–75 years of age who had appropriate screening for colorectal
cancer through one of these measures: fecal occult blood test (FOBT) during the current
measurement period, flexible sigmoidoscopy during the measurement period or the four
prior measurement periods, or colonoscopy during the current measurement period or the
nine prior measurement periods. (USPSTF guideline)
Well-child visits in the
first 15 months of life
The percentage of patients who turned 15 months old during the measurement period with
six or more well-child visits with a PCP.
Well-child visits in the
The percentage of patients 3–6 years of age who received one or more well-child visits with
third, fourth, fifth, and sixth
a PCP during the current measurement period.
years of life
Weight assessment and
counseling for Nutrition
and Physical Activity for
Children/Adolescents
The percentage of patients 3–17 years of age who receive BMI, nutrition, and physical
activity counseling during an annual visit.
• COMMERCIAL
INTEGRATION
• QUEST
• HMSA AKAMAI ADVANTAGE
For more details, see Appendix A.
9
Pay-for-Quality Clinical Measures (continued)
Childhood Immunizations
Percentage of children having all of the following immunizations on or before their second birthday.
••
••
••
••
••
••
••
INDIVIDUAL
IMMUNIZATION
HIGH-LEVEL DEFINITION
Diphtheria, Tetanus, and
Acellular Pertussis (DTaP)
At least four DTaP vaccinations with different dates of service on or before the child’s second
birthday. DTaP administered prior to 42 days after birth can't be counted.
Haemophilus
Influenzae
Type b (Hib)
Hepatitis B (HepB)
At least three Hib vaccinations with different dates of service on or before the child’s second
birthday. Hib administered prior to 42 days after birth can't be counted.
At least two outpatient HepB vaccinations with different dates of service on or before the
child’s second birthday.
Inactivated Poliovirus
(IPV)
At least three IPV vaccinations with different dates of service on or before the child’s second
birthday. IPV administered prior to 42 days after birth can't be counted.
Measles, Mumps,
& Rubella (MMR)
At least one MMR vaccination with a date of service on or before the child’s second birthday.
Pneumococcal
Conjugate (PCV)
At least four PCV vaccinations with different dates of service on or before the child’s second
birthday. PCV administered prior to 42 days after birth can't be counted.
Varicella (VZV)
At least one VZV vaccination with a date of service on or before the child’s second birthday.
Immunizations for Adolescents
Percentage of adolescents having all of the following immunizations on or before their 13th birthday.
INDIVIDUAL
IMMUNIZATION
••
Meningococcal
••
Tetanus, Diphtheria, and
Acellular Pertussis (Tdap)
or Tetanus and Diphtheria
(Td)
HIGH-LEVEL
DEFINITION
One meningococcal vaccine on or between the adolescent’s 7th and 13th birthdays.
One Tdap or one Td between the adolescent's 10th and 13th birthdays.
• COMMERCIAL
INTEGRATION
• QUEST
HMSA
AKAMAI
ADVANTAGE
•
For more details, see Appendix A.
10
Pay-for-Quality Clinical Measures (continued)
Heart Disease
MEASURE
•••
HIGH-LEVEL DEFINITION
The percentage of patients 18–85 years of age who had a diagnosis of hypertension and
whose blood pressure was adequately controlled during the measurement period based on
the most recent blood pressure reading during the measurement period (after diagnosing
Controlling blood pressure
hypertension) according to the following criteria:
– Members 18–59 years of age whose BP was <140/90 mm Hg.
– Members 60–85 years of age whose BP was <150/90 mm Hg.
•
Medication adherence
for cholesterol (statins)
The percentage of patients 18 years of age or older who adhered to their prescribed drug
therapy for statin cholesterol medications by meeting the proportion of days covered
threshold of 80 percent during the measurement year.
•
Medication adherence
for hypertension
(RAS antagonist)
The percentage of patients 18 years of age or older who adhered to their prescribed drug
therapy for renin angiotensin system (RAS) antagonist medication by meeting the proportion
of days covered threshold of 80 percent during the measurement year.
Comprehensive Diabetes Care
MEASURE
•••
Blood pressure control
<140/90
•••
Eye exam
•
HbA1c control (<8.0%)
•
HIGH-LEVEL DEFINITION
The percentage of patients with diabetes 18–75 years of age whose most recent blood
pressure reading during the measurement period was <140/90 mm Hg.
The percentage of patients with diabetes 18–75 years of age who received a retinal or
dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the current
measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care
professional in the prior measurement period. (American Diabetes Association guideline)
The percentage of patients with diabetes age 18–75 years whose most recent HbA1c test
during the measurement period is <8.0 percent.
•
HbA1c in control
(≤9)
The percentage of patients with diabetes age 18–75 years whose most recent HbA1c test
during the measurement period is ≤9.0 percent or whose HbA1c wasn't measured during the
measurement period.
•
Medication adherence for
oral diabetes medications
The percentage of patients 18 years of age or older who adhered to their prescribed drug
therapy across four classes of oral diabetes medications – biguanides, sulfonylureas,
thiazolidinediones, and dipeptidyl peptidase-IV (DPP-IV) inhibitors – by meeting the proportion
of days covered threshold or 80 percent during the measurement period.
Medical attention for
nephropathy
The percentage of patients with diabetes 18–75 years of age who had at least one test for
microalbumin during the current measurement period or who had evidence of medical
attention for existing nephropathy (diagnosis of nephropathy or documentation of
microalbuminuria or albuminuria; ACE inhibitor/ARB therapy during the measurement period
is also acceptable evidence). (American Diabetes Association guideline)
•••
• COMMERCIAL
INTEGRATION
• QUEST
• HMSA AKAMAI ADVANTAGE
For more details, see Appendix A.
11
Pay-for-Quality Clinical Measures (continued)
Appropriate Respiratory Care
MEASURE
HIGH-LEVEL DEFINITION
••
Appropriate testing for
children with pharyngitis
The percentage of children 2–18 years of age who were diagnosed with pharyngitis,
prescribed an antibiotic, and received a group A streptococcus (strep) test for the episode.
A higher rate represents better performance (i.e., appropriate testing).
••
Appropriate treatment
for children with upper
respiratory infection
The percentage of children 3 months–18 years of age who were given a diagnosis of upper
respiratory infection and weren’t dispensed an antibiotic prescription.
•
Avoidance of antibiotic
treatment in adults with
acute bronchitis
The percentage of patients 18–64 years of age with a diagnosis of acute bronchitis who
weren't dispensed an antibiotic prescription. (This measure is reported as an inverted rate.
A higher rate indicates appropriate treatment of adults with acute bronchitis.)
••
Medication management
for people with asthma
The percentage of patients 5–85 years of age during the measurement year who were
identified as having persistent asthma, dispensed appropriate medications, and were
adherent during the treatment period.
Chronic Disease Review
•
MEASURE
HIGH-LEVEL DEFINITION
Review of Chronic
Conditions
The percentage of chronic condition groupings or codes that were identified in the two years
prior that are persistent during the measurement period as confirmed by claims or
disconfirmed by provider attestation. Note: Information from the Cozeva Coding Specificity
(CCS) tool will be displayed. See page 68 for details.
• COMMERCIAL
INTEGRATION
• QUEST
• HMSA AKAMAI ADVANTAGE
12
Patient Population and Member Eligibility
Patient Population Identification
Member Eligibility
COMMERCIAL
To be included in a provider’s performance rate calculations,
members must be assigned to the provider’s patient panel and
be eligible HMSA members for at least nine of the 12 months in
the measurement period.
HMSA’s Commercial plans (HMO and PPO) are eligible for the
program.
HMSA AKAMAI ADVANTAGE
All members eligible for a measure, whether or not they meet
this requirement, will contribute to a provider’s maximum payment potential for each of the months they are attributed to the
provider.
Only HMSA Akamai Advantage plans are currently eligible for
the program.
If a member participates in another plan in addition to HMSA
Akamai Advantage, the member can only be counted under one
of the pay-for-quality programs as follows:
For the review of chronic conditions measure, however, additional
criteria must be met for a member to contribute to maximum payment potential:
• If a member under HMSA Akamai Advantage also has
coverage under HMSA’s Commercial plan, the member will be
counted under the Commercial pay-for-quality program.
• Members must be assigned to the provider’s patient panel
and be eligible HMSA members for at least six of the nine
months in the measurement period.
• If a member under HMSA Akamai Advantage also has
coverage under The HMSA Plan for QUEST Integration
Members, the member will be counted under the
HMSA Akamai Advantage pay-for-quality program.
• The eligible member must have at least one condition in the
measure’s denominator; and
QUEST INTEGRATION
• The provider must render services to and/or submit at least
one claim for the eligible member.
HMSA's QUEST Integration plan is eligible for the program.
Member Eligibility for Specific Measures
COMMERCIAL • QUEST INTEGRATION
The childhood immunization status measure requires the
following:
• Members must have a PCP relationship with a pediatrician
(as defined by the patient panel rules) and be eligible HMSA
members during at least 11 of the 12 months prior to turning
2 years old, as well as during the month the member turns
2 years old.
13
Pay-for-Quality Payment
Payment Conditions
Examples of scoring are provided per line of business in subsequent sections of this program guide.
To be eligible, a provider must meet all of the following criteria:
• Participate in:
Payment Philosophy
–H
MSA’s PPO plan, for Commercial and QUEST Integration
pay-for-quality.
Under the primary care pay-for-quality program, payment varies
predictably with the provider’s performance and improvement
within the quality measures based on a predetermined formula.
The provider is paid for performance as well as improvement in a
given measure. Points scored for performance and for
improvement determine total points, which translate into
monetary awards.
– HMSA Akamai Advantage at the end of the measurement
period, for HMSA Akamai Advantage pay-for-quality.
• Participate in a PCMH program for Commercial and HMSA
Akamai Advantage pay-for-quality.
• Practice in the state of Hawaii at the end of each measurement
period.
COMMERCIAL • QUEST INTEGRATION
The variable payment formula calculation for Commercial and
QUEST Integration Pay-for-Quality will be based on:
• Submit claims to HMSA that indicate a face-to-face encounter,
during the measurement period. For example, at least one such
Medicare Advantage claim must be submitted during the
measurement period for HMSA Akamai Advantage pay-for-quality.
• Patient panel count.
• Pay-for-quality per member per month (PMPM) budget.
(In 2016, the Commercial PMPM is $4.25 and the QUEST
Integration PMPM is $2.75.)
See, also, details under the Program Eligibility and Enrollment
sections on page 3.
If the provider or group administrator is eligible to receive an
award, the award check and remittance report will be sent to
the payee(s) that the provider or group administrator
designated for HMSA claims payments as of the end of each
measurement period.
• Measure weighting.
– Individual measure patient panel count.
– Individual measure importance and effort.
• Performance levels determine points earned per measure.
• Points earned and weighting are factors that determine the
actual portion of the potential award earned.
Quality Payments
For a more detailed explanation of payment formulas, see
Example Quality Performance Report and Quality Scoring
Calculations (Commercial, pages 18-25; QUEST Integration,
pages 28-34).
Pay-for-quality payments are based on your cumulative
performance during the measurement period compared to your
performance during the corresponding baseline period. See
Scoring Period tables on page 5, for details on Commercial,
QUEST Integration, and HMSA Akamai Advantage 2016 pay-forquality programs’ performance and baseline periods.
HMSA AKAMAI ADVANTAGE
The variable payment formula calculation for
HMSA Akamai Advantage pay-for-quality will be based on:
Performance quality reports are sent out about two months after
the end of each quarter. Commercial and QUEST Integration
pay-for-quality performance payments will be included with these
reports, while HMSA Akamai Advantage will be scored for payment at the end of the measurement year. The program schedule
allows for a one-month claims run-out, one month for validation,
and one month for processing. Reconciliations for Commercial
and QUEST Integration pay-for-quality will be made quarterly.
For detailed program schedules, see the Target Dates and
Deliverables tables on page 4.
• Patient panel count per measure.
• The amount budgeted per member per measure for
pay-for-quality per member per month (PMPM) depending on
the measure. See PMPMs for the HMSA Akamai Advantage
pay-for-quality program on page 36.
• Measurement-period performance compared to
baseline-period performance and performance Stars levels
determine points earned per measure.
The programs establish a maximum payment potential per line of
business. See the Maximum Payment Potential section for
Commercial (page 15), QUEST Integration (page 26), and
HMSA Akamai Advantage (page 35) for details. The portion you
earn — your annual pay-for-quality payment — is determined by
a threshold scoring model. This model allocates points based on
a provider’s performance compared to percentile levels (or Stars
levels, for HMSA Akamai Advantage) and improvement over the
levels achieved during the baseline period.
• Points earned, which determine the actual portion of the
maximum payment potential earned.
For a more detailed explanation of payment formulas, see
Example Quality Performance Report and Quality Scoring
Calculations (pages 35-43).
NOTE: New PCPs without a 2015 Performance Quality Report are eligible for performance points only, because there’s no baseline to
compare against for improvement points. Similarly, PCPs only earn performance points on new measures, because there are no
baselines for improvement points.
14
Commercial Pay-for-Quality Payment
Commercial Total
Maximum Payment Potential
COMMERCIAL
The primary care pay-for-quality program counts the eligible
patients in the PCP’s primary care panel at the end of each
month. The monthly values are added to generate a quarterly
subtotal. Then, that count is multiplied by $4.25 to calculate the
total maximum payment potential for that quarter.
For example:
On January 31, 2016, a provider has 1,063 eligible HMSA
patients, 1,061 patients on February 28, 2016, and 1,065 patients
on March 31, 2016. The provider’s estimated member months are
3,189 (1,063 + 1,061 + 1,065). The maximum payment potential =
$13,553.25 (3,189 x $4.25).
PRIMARY
CARE PATIENT
COUNT
PMPM
AMOUNT
TOTAL
MONTHLY
POTENTIAL
January
1,063
$4.25
$4,517.75
February
1,061
$4.25
$4,509.25
March
1,065
$4.25
$4,526.25
Quarter 1
Subtotal
3,189
April
1,063
$4.25
$4,517.75
May
1,061
$4.25
$4,509.25
June
1,065
$4.25
$4,526.25
Quarter 2
Subtotal
3,189
July
1,063
$4.25
$4,517.75
August
1,061
$4.25
$4,509.25
September
1,065
$4.25
$4,526.25
Quarter 3
Subtotal
3,189
October
1,050
$4.25
$4,462.50
November
1,150
$4.25
$4,887.50
December
1,200
$4.25
$5,100.00
Quarter 4
Subtotal
3,400
$14,450.00
Annual
Total
12,967
$55,109.75
MONTH
$ 13,553.25
$13,553.25
$13,553.25
15
Commercial
2016 Performance Quality Report Example
COMMERCIAL
To work through the following examples, consult the quarterly 2016 Performance Quality Report for Dr. Aloha Lee (internal medicine) on
this page.
Performance Period:
Baseline Period:
Provider: Lee, Aloha
Est. Member Months: 3,189
4/1/2015 to 3/31/2016
4/1/2014 to 3/31/2015
†
Total Max Pay Potential :
$13,553.25
PERFORMANCE
RATE
BASELINE
PERCENTILE
17
85%
90th
90th
12.5
$152.24
$190.30
5
4
80%
75th
25th
0.0
$38.06
$0.00
1
5
5
100%
90th
90th
12.5
$19.03
$23.79
1
30
27
90%
90th
90th
12.5
$114.18
$142.73
0.15
600
550
91.67%
75th
50th
4.0
$342.54
$137.02
Breast Cancer Screening
1
453
350
77.26%
75th
25th
0.0
$1,724.13
$0.00
Cervical Cancer Screening
1
671
541
80.63%
90th
50th
4.0
$2,553.84
$1,021.54
Childhood Immunization
Status
4
4
4
100%
75th
90th
12.5
$60.90
$76.12
Chlamydia Screening for
Women
1
16
16
100%
90th
90th
12.5
$60.90
$76.12
Colorectal Cancer
Screening
1
756
721
95.37%
75th
90th
12.5
$2,877.35
$3,596.69
Comprehensive Diabetes
Care – Blood Pressure
Control (<140/90)
2
92
80
86.96%
90th
90th
12.5
$700.31
$875.39
Comprehensive Diabetes
Care – Eye Exam
1
92
71
77.17%
75th
75th
8.0
$350.15
$280.12
Comprehensive Diabetes
Care – HbA1c Control
(≤9.0)
2
92
88
95.65%
90th
90th
12.5
$700.31
$875.39
Comprehensive Diabetes
Care – Medical Attention
for Nephropathy
1
92
88
95.65%
90th
90th
12.5
$350.15
$437.69
Controlling Blood Pressure
2
420
351
83.57%
75th
75th
8.0
$3,197.06
$2,557.65
Immunizations for
Adolescents
1
11
6
54.55%
<10th
10th
2.0
$41.87
$8.37
Medication Management
for People with Asthma
(75% Compliance)
3
10
10
100%
75th
90th
12.5
$114.18
$142.73
MEASURE
WEIGHT
DEMONINATOR
Advance Care Planning
2
20
Appropriate Testing for
Children with Pharyngitis
2
Appropriate Testing for
Children with Upper
Respiratory Infection
Avoidance of Antibiotic
Treatment in Adults with
Acute Bronchitis
Body Mass Index
Assessment
NUMERATOR
† Total Max Pay Potential = Member Months x PMPM Rate.
16
PERCENTILE
POINTS
MAX
PAYMENT
PAYMENT
EARNED
PERFORMANCE
RATE
BASELINE
PERCENTILE
75
75%
50th
50th
4
$57.09
$22.84
2
1
50%
<10th
<10th
0
$22.84
$0.00
2
10
8
80%
75th
50th
4
$76.12
$30.45
31.30
3,481
$13,553.25
$10,494.92
MEASURE
WEIGHT
DEMONINATOR
0.15
100
Well-Child Visits in the First
15 months of Life
3
Well-Child Visits in the
Third, Fourth, Fifth, and
Sixth years of Life
Weight Assessment and
Counseling for Nutrition
and Physical Activity for
Children/Adolescents
Total
NUMERATOR
† Est. Max Quality Pay = Member Months x PMPM Rate.
17
PERCENTILE
POINTS
MAX
PAYMENT
PAYMENT
EARNED
Commercial Quality Scoring Calculations
Step 1: Calculation of Maximum Payment for Each Measure
COMMERCIAL
a. Weigh the Patient Panel of the Measure
• Divide the measure denominator by the total of all
denominators. The result is the patient panel weight factor
for the measure.
Example:
Dr. Lee’s breast cancer screening is 453 / 3,481 =
0.1301350187.
b. Weigh the Measure Importance and Effort.
• Divide the measure importance weight by the total of all
weights.
Example:
The breast cancer screening importance weight is 1.
The total of all weights is 31.3. Dr. Lee’s breast cancer
screening adjustment factor is 1/31.3 = 0.0319488818.
c. Combine Weight
• Multiply the patient panel measure weight factor
(from section a) by the importance and effort weight
factor (from section b) for a combined weight factor for
each measure.
Example:
Dr. Lee’s breast cancer screening combined weight factor
is 0.1301350187 x 0.0319488818 = 0.0041576683.
d. Total Combined Weight Factors
• Add the combined weight factors (from section c) of all
measures for total combined weight.
Example:
Dr. Lee’s Total Combined Weight Factor is 0.0326831278.
e. Normalize Combined Weight Factors
• Divide the combined weight factor for each measure (from
section c) by the total combined weight (from section d).
This is the normalized combined weight factor.
Example:
Dr. Lee’s breast cancer screening normalized weight
factor is 0.0041576683 / 0.0326831278 = 0.1272114567.
f. Calculate Max Payment for Each Measure
• Multiply the normalized combined weight for each
measure (from section e) by the Total Max Pay Potential
(top section of the 2016 Performance Quality Report
above) to calculate the Max Payment.
Example:
Dr. Lee’s breast cancer screening max payment is
1272114567 x $13,553.25 = $1,724.13.
† Est. Max Quality Pay = Member Months x PMPM Rate.
18
Commercial Calculating Measure Maximum Payment Example
COMMERCIAL
MEASURES
COMBINED
WEIGHT
(DENOMINATOR/TOTAL
DENOMINATORS) X
(MEASURE
WEIGHT/
TOTAL
MEASURE
WEIGHTS)
COMBINED
WEIGHT
NORMALIZED
WEIGHT
CALCULATION
(COMBINED
WEIGHT/
TOTAL
COMBINED
WEIGHT)
NORMALIZED
WEIGHT
MAX
PAYMENT
CALCULATION (NORMALIZED
WEIGHT/
TOTAL MAX
PAY POTENTIAL)
MAX
PAYMENT
1. Advance Care Planning
(20/3,481) x
(2/31.3)
0.0003671230
0.0003671230 /
0.0326831278
0.0112327980
0.0112327980 /
$13,553.25
$152.24
2. Appropriate Testing for
Children with Pharyngitis
(5/3,481) x
(2/31.3)
0.0000917808
0.0000917808 /
0.0326831278
0.0028081999
0.0028081999 /
$13,553.25
$38.06
3. Appropriate Testing for
Children with Upper
Respiratory Infection
(5/3,481) x
(1/31.3)
0.0000458904
0.0000458904 /
0.0326831278
0.0014041000
0.0014041000 /
$13,553.25
$19.03
4. Avoidance of Antibiotic Treatment in Adults with Acute
Bronchitis
(30/3,481) x
(1/31.3)
0.0002753423
0.0002753423 /
0.0326831278
0.0084245998
0.0084245998 /
$13,553.25
$114.18
5. Body Mass Index Assessment
(600/3,481) x
(.15/31.3)
0.0008260268
0.0008260268 /
.0326831278
0.0252737995
0.0252737995 /
$13,553.25
$342.54
6. Breast Cancer Screening
(453/3,481) x
(1/31.3)
0.0041576683
0.0041576683 /
0.0326831278
0.1272114567
0.1272114567 /
$13,553.25
$1,724.13
7. Cervical Cancer Screening
(671/3,481) x
(1/31.3)
0.0061584888
0.0061584888 /
0.0326831278
0.1884302162
0.1884302162 /
$13,553.25
$2,553.84
8. Childhood Immunization
Status (All individual
immunizations)
(4/3,481) x
(4/31.3)
0.0001468492
0.0001468492 /
0.0326831278
0.0044931199
0.0044931199 /
$13,553.25
$60.90
9. Chlamydia Screening for
Women
(16/3,481) x
(1/31.3)
0.0001468492
0.0001468492 /
0.0326831278
0.0044931199
0.0044931199 /
$13,553.25
$60.90
10. Colorectal Cancer Screening
(756/3,481) x
(1/31.3)
0.0069386253
0.0069386253 /
0.0326831278
0.2122999158
0.2122999158 /
$13,553.25
$2,877.35
11. Comprehensive Diabetes Care –
Blood Pressure Control
(92/3,481) x
(2/31.3)
0.0016887659
0.0016887659 /
0.0326831278
0.0516708790
0.0516708790 /
$13,553.25
$700.31
12. Comprehensive Diabetes Care
– Eye Exam
(92/3,481) x
(1/31.3)
0.0008443830
0.0008443830 /
0.0326831278
0.0258354395
0.0258354395 /
$13,553.25
$350.15
13. Comprehensive Diabetes Care
– HBA1c in Control (≤9)
(92/3,481) x
(2/31.3)
0.0016887659
0.0016887659 /
0.0326831278
0.0516708790
0.0516708790 /
$13,553.25
$700.31
14. Comprehensive Diabetes
Care – Medical Attention for
Nephropathy
(92/3,481) x
(1/31.3)
0.0008443830
0.0008443830 /
0.0326831278
0.0258354395
0.0258354395 /
$13,553.25
$350.15
15. Controlling Blood Pressure
(420/3,481) x
(2/31.3)
0.0077095837
0.0077095837 /
0.0326831278
0.2358887953
0.2358887953 /
$13,553.25
$3,197.06
16. Immunizations for Adolescents
(All individual immunizations)
(11/3,481) x
(1/31.3)
0.0001009588
0.0001009588 /
0.0326831278
0.0030890199
0.0030890199 /
$13,553.25
$41.87
17. Medication Management for
People With Asthma
(10/3,481) x
(3/31.3)
0.0002753423
0.0002753423 /
0.0326831278
0.0084245998
0.0084245998 /
$13,553.25
$114.18
18. Weight Assessment and
Counseling for Nutrition and
Physical Activity for Children/
Adolescents
(100/3,481) x
(.15/31.3)
0.0001376711
0.0001376711 /
0.0326831278
0.0042122999
0.0042122999 /
$13,553.25
$57.09
19
Commercial Calculating Measure Maximum Payment Example
COMBINED
WEIGHT
(DENOMINATOR/TOTAL
DENOMINATORS) X
(MEASURE
WEIGHT/
TOTAL
MEASURE
WEIGHTS)
MEASURES
COMBINED
WEIGHT
NORMALIZED
WEIGHT
CALCULATION
(COMBINED
WEIGHT/
TOTAL
COMBINED
WEIGHT)
NORMALIZED
WEIGHT
MAX
PAYMENT
CALCULATION (NORMALIZED
WEIGHT/
TOTAL MAX
PAY POTENTIAL)
MAX
PAYMENT
19. Well-Child Visits in the First 15
months of life
(2/3,481) x
(3/31.3)
0.0000550685
0.0000550685 /
0.0326831278
0.0016849200
0.0016849200 /
$13,553.25
$22.84
20. W
ell-Child Visits in the Third,
Fourth, Fifth, and Sixth years
of life
(10/3,481) x
(2/31.3)
0.0001835615
0.0001835615 /
0.0326831278
0.0056163999
0.0056163999 /
$13,553.25
$76.12
TOTAL COMBINED WEIGHT:
0.0326831278
20
TOTAL MAXIMUM PAYMENT
POTENTIAL:
$13,553.25
Commercial Quality Scoring Calculations
Step 2: Performance and Improvement Points Earned
COMMERCIAL
To calculate performance and improvement points and the
portion of the Max Payment that will be earned for each measure,
follow these steps. The figures below use numbers from measures on Dr. Lee’s example 2016 Performance Quality Report.
a.Determine the performance level that the current performance rate falls into (the level at which the performance rate
is greater than or equal to, but less than the next highest
percentile level). See the National Percentile Threshold Rates
Table, page 23.
Example:
For breast cancer, Dr. Lee’s performance rate is 77.26
percent. The performance rate of 77 percent falls between
the 25th (72.37 percent) and 50th (78.39 percent) percentile
using the National Percentile Threshold Rates Table. The
breast cancer performance rate is in the 25th percentile.
b.The baseline percentile, along with the current performance
percentile, is used to determine the performance and
improvement points. (Performance and Improvement Points
by Performance Level Tables, pages 24-25.)
Examples:
Dr. Lee’s baseline performance for advanced care planning
was in the 90th percentile. Dr. Lee’s current performance
percentile for advanced care planning is in the 90th percentile. Using the Performance and Improvement Points by
Percentile Range Tables, Dr. Lee earned 10 performance
points and 2.5 improvement points for a total of 12.5 points.
Dr. Lee’s baseline performance for breast cancer screening
was in the 75th percentile. Dr. Lee’s current performance
percentile for breast cancer screening is in the 25th percentile. Using the Performance and Improvement Points by
Percentile Range Tables, Dr. Lee earned 0 performance
points and 0 improvement points for a total of 0 points.
21
Commercial Quality Scoring Calculations
Step 3: Calculation of Actual Payment for Each Measure
COMMERCIAL
Multiply the maximum payment for each measure by the total
points earned. Divide the result by 10 to determine the actual
payment earned for each measure.
Example:
Dr. Lee’s maximum payment for colorectal cancer screening
was $2,877.35. Dr. Lee earned 12.5 total points for colorectal cancer screening. Dr. Lee’s actual payment earned for
colorectal cancer screening is ($2,877.35 x 12.5 points) / 10 =
$3,596.69.
Each measure has a budget of 10 performance points. A provider
may exceed the performance points by earning bonus points on
individual measures. The total payment earned amount (total of
all payments earned for all measures) is capped at 110 percent of
the total maximum payment potential.
Providers must score at least 40 percent overall in each program
(Commercial, QUEST Integration, and HMSA Akamai Advantage)
to qualify for payment in the respective line of business. For
example, if a provider scores 82 percent overall in Commercial
and 31 percent overall in QUEST Integration, the provider will be
awarded earned dollars for Commercial, but will not be awarded
earned dollars for QUEST Integration.
22
COMMERCIAL
National Percentile Threshold Rates – Clinical Measures†
Threshold Scale Selection
COMMERCIAL MEASURES
10TH
25TH
50TH
75TH
90TH
Advance Care Planning
30.00
40.00
50.00
60.00
70.00
Appropriate Testing for Children with Pharyngitis
59.72
71.94
81.80
90.81
95.88
Appropriate Testing for Children with Upper
Respiratory Infection
71.00
80.29
87.49
96.87
99.64
Avoidance of Antibiotic Treatment in Adults with
Acute Bronchitis
16.15
20.74
25.99
45.64
60.20
Body Mass Index Assessment
64.77
76.18
87.21
93.94
99.02
Breast Cancer Screening
68.70
72.37
78.39
82.49
86.28
Cervical Cancer Screening
69.33
72.85
77.34
81.25
86.36
Childhood Immunization Status
(All individual immunizations)
72.00
79.00
83.24
89.50
91.78
Chlamydia Screening for Women
32.97
36.37
43.43
55.08
70.60
Colorectal Cancer Screening
50.56
61.07
68.27
74.41
79.61
Comprehensive Diabetes Care – Eye Exam
35.67
49.91
63.41
74.51
80.11
Comprehensive Diabetes Care – HbA1c
In Control ≤9
59.03
71.21
76.09
81.81
83.6
Comprehensive Diabetes Care –
Medical Attention for Nephropathy
79.80
82.72
88.57
93.00
95.51
Comprehensive Diabetes Care – Blood Pressure
Control
58.91
65.40
72.34
78.46
85.94
Controlling Blood Pressure
52.82
63.07
68.78
76.70
88.86
Immunizations for Adolescents
(All individual immunizations)
48.11
63.71
73.88
85.87
89.56
Medication Management for People with Asthma
34.51
39.02
43.80
52.31
60.72
Weight Assessment and Counseling for Nutrition
and Physical Activity for Children/Adolescents
3.97
43.82
62.36
75.09
95.76
Well-Child Visits in the First 15 months of life
66.57
73.00
81.86
87.94
92.09
Well-Child Visits in the Third, Fourth, Fifth, and
Sixth years of life
57.86
62.28
74.33
80.47
86.89
† Percentile ranks reflect the provider network performance for a large number of health plans (actual numbers vary by measure).
These percentile levels are from NCQA Quality Compass®.
Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).
23
COMMERCIAL
Performance and Improvement Points by Performance Level Tables
The following tables correspond to the six possible Baseline Period Performance levels and detail the performance and improvement
points earned based on current measurement period performance. Select the table that corresponds to your baseline performance
level for each measure. Locate the row that describes your current-period performance percentile level and note the total points
earned for each measure.
Table 1: Baseline Period Performance: < 10th Percentile
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
2
2
25 percentile
0
3
3
50th percentile
4
2
6
75 percentile
8
2.5
10.5
10
2.5
12.5
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
th
th
th
90 percentile
th
Table 2: Baseline Period Performance: 10 Percentile
th
MEASUREMENT PERIOD PERFORMANCE
<10th percentile
0
0
0
10th percentile
0
0
0
25th percentile
0
2
2
50 percentile
4
2
6
75 percentile
8
2.5
10.5
10
2.5
12.5
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
th
th
90 percentile
th
Table 3: Baseline Period Performance: 25 Percentile
th
MEASUREMENT PERIOD PERFORMANCE
<10th percentile
0
0
0
10th percentile
0
0
0
25th percentile
0
0
0
50 percentile
4
2
6
75 percentile
8
2.5
10.5
90th percentile
10
2.5
12.5
th
th
24
COMMERCIAL
Table 4: Baseline Period Performance: 50th Percentile
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
0
0
25 percentile
0
0
0
50th percentile
4
0
4
75 percentile
8
2.5
10.5
90 percentile
10
2.5
12.5
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
th
th
th
th
Table 5: Baseline Period Performance: 75th Percentile
MEASUREMENT PERIOD PERFORMANCE
<10th percentile
0
0
0
10th percentile
0
0
0
25th percentile
0
0
0
50 percentile
4
0
4
th
75 percentile
8
0
8
90th percentile
10
2.5
12.5
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
SUSTAINED
EXCELLENCE
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
0
0
25 percentile
0
0
0
50th percentile
4
0
4
75 percentile
8
0
8
90 percentile
10
2.5
12.5
th
Table 6: Baseline Period Performance: 90th Percentile
th
th
th
th
25
QUEST Integration Quality Scoring Calculations
Total Maximum Payment Potential
QUEST INTEGRATION
The primary care pay-for-quality program counts the eligible
patients in the PCP’s primary care panel at the end of each
month. The monthly values are added to generate a quarterly
subtotal. That count is multiplied by $2.75 to calculate the total
maximum payment potential.
For example:
On January 31, 2016, a provider has 1,063 eligible HMSA
patients, 1,061 patients on February 28, 2016, and 1,065 patients
on March 31, 2016. For the first quarter in 2016, the provider’s
estimated member month total is 3,189 (1,063 + 1,061 + 1,065).
The maximum payment potential = $8,769.75 (3,189 x $2.75).
PRIMARY
CARE PATIENT
COUNT
PMPM
AMOUNT
TOTAL
MONTHLY
POTENTIAL
January
1,063
$2.75
$2,923.25
February
1,061
$2.75
$2,917.75
March
1,065
$2.75
$2,928.75
Quarter 1
Subtotal
3,189
April
1,063
$2.75
$2,923.25
May
1,061
$2.75
$2,917.75
June
1,065
$2.75
$2,928.75
Quarter 2
Subtotal
3,189
July
1,063
$2.75
$2,923.25
August
1,061
$2.75
$2,917.75
September
1,065
$2.75
$2,928.75
Quarter 3
Subtotal
3,189
October
1,063
$2.75
$2,923.25
November
1,061
$2.75
$2,917.75
December
1,065
$2.75
$2,928.75
Quarter 4
Subtotal
3,189
$8,769.75
Annual
Total
12,756
$35,079.00
MONTH
$8,769.75
$8,769.75
$8,769.75
26
QUEST Integration
2016 Performance Quality Report Example
QUEST INTEGRATION
To work through the following examples, consult the quarterly Performance Quality Report for Dr. Aloha Lee (internal medicine) on this page.
Performance Period:
4/1/2015 to 3/31/2016
Baseline Period:
4/1/2014 to 3/31/2015
Provider: Lee, Aloha
Est. Member Months: 3,189
Total Max Pay Potential: $8,769.75
MEASURE
WEIGHT
DEMONINATOR
NUMERATOR
PERFORMANCE
RATE
BASELINE
PERCENTILE
Appropriate Testing for
Children with Pharyngitis
2
5
4
80.00%
75th
75th
8.0
$25.12
$20.10
Appropriate Testing for
Children with Upper
Respiratory Infection
1
5
5
100.00%
75th
90th
12.5
$12.56
$15.70
0.15
600
500
83.33%
50th
50th
4.0
$226.09
$90.44
Breast Cancer Screening
1
453
350
77.26%
90th
90th
12.5 $1,137.98
$1,422.48
Cervical Cancer Screening
1
671
541
80.63%
90th
90th
12.5 $1,685.62
$2,107.03
Childhood Immunization
Status
4
4
4
100.00%
90th
90th
12.5
$40.19
$50.24
Chlamydia Screening for
Women
1
16
16
100.00%
90th
90th
12.5
$40.19
$50.24
Colorectal Cancer
Screening
1
756
500
66.14%
90th
25th
0.0 $1,899.15
$0.00
Comprehensive Diabetes
Care – Blood Pressure
Control (<140/90)
2
92
80
86.96%
90th
90th
12.5
$462.23
$577.78
Comprehensive Diabetes
Care – Eye Exam
1
92
71
77.17%
90th
90th
12.5
$231.11
$288.89
Comprehensive Diabetes
Care – HbA1c Control
(<8.0)
2
92
85
92.39%
90th
90th
12.5
$462.23
$577.78
Comprehensive Diabetes
Care – Medical Attention
for Nephropathy
1
92
88
95.65%
90th
90th
12.5
$231.11
$288.89
Controlling Blood Pressure
2
420
250
59.52%
50th
50th
4.0 $2,110.17
$844.07
Immunizations for
Adolescents
1
11
7
63.64%
<10th
25th
3.0
$27.63
$8.29
Medication Management
for People with Asthma
(75% Compliance)
3
10
10
100.00%
90th
90th
12.5
$75.36
$94.20
Weight Assessment and
Counseling for Nutrition
and Physical Activity for
Children/Adolescents
0.15
100
75
75.00%
75th
75th
8.0
$37.68
$30.15
Well-Child Visits in the
First 15 months of Life
3
2
1
50.00%
<10th
<10th
0.0
$15.07
$0.00
Well-Child Visits in the
Third, Fourth, Fifth, and
Sixth years of Life
2
10
80.00%
50th
50th
4.0
$50.24
$20.10
28.30
3,431
$8,769.75
$6,486.37
Body Mass Index
Assessment
Total
8
27
PERCENTILE
POINTS
MAX
PAYMENT
PAYMENT
EARNED
Quest Integration Quality Scoring Calculations
Step 1: Calculation of Maximum Payment for Each Measure
QUEST INTEGRATION
a. Weigh the Patient Panel of the Measure
• Divide the measure denominator by the total of all
denominators. The result is the patient panel weight
factor for the measure.
Example:
Dr. Lee’s breast cancer screening is 453 / 3,431 =
0.1320314777.
b. Weigh the Measure Importance and Effort
•Divide the measure importance weight by the total of all
weights.
Example:
The breast cancer screening importance weight is 1.
The total of all weights is 28.3.
Dr. Lee’s breast cancer screening adjustment factor is
1/28.3 = 0.0353356890.
c. Combine Weight Factors
•Multiply the patient panel measure weight factor
(from section a) by the importance and effort weight
factor (from section b) for a combined weight factor for
each measure.
Example:
Dr. Lee’s breast cancer screening combined weight factor
is 0.1320314777 x 0.0353356890 = 0.0046654232.
d. Total Combined Weight Factors
• Add the combined weight factors (from section c) of all
Dr. Lee’s measures for the total combined weight.
Example:
Dr. Lee’s total combined weight factor is 0.0359536258.
e. Normalize Combined Weight Factors
• Divide the combined weight factor for each measure
(from section c) by the total combined weight (from
section d). This is the normalized combined weight.
Example:
Dr. Lee’s breast cancer screening normalized combined weight factor is 0.0046654232 / 0.0359536258 =
.1297622450.
f. Calculate Max Payment for Each Measure
•Multiply the normalized combined weight for each
measure (from section e) by the Total Max Pay Potential
(top section of the 2016 Performance Quality Report
above) to calculate the Max Payment for each measure.
Example:
Dr. Lee’s breast cancer screening max payment is
.1297622450 x $8,769.75 = $1,137.98.
† Est. Max Quality Pay = Member Months x PMPM Rate.
28
QUEST Integration Calculating Measure Maximum Payment
Example
QUEST INTEGRATION
The importance of weight factors are determined by the degree of difficulty required to complete the particular clinical process for each
measure and the importance of the measure on HMSA’s accreditation ranking.
MAX
PAYMENT
CALCULATION
(NORMALIZED
WEIGHT/
TOTAL MAX
PAY POTENTIAL)
COMBINED
WEIGHT CALCULATIONS
(DENOMINATOR/TOTAL
DENOMINATORS) X
(MEASURE
WEIGHT/TOTAL MEASURE
WEIGHTS)
COMBINED
WEIGHT
Appropriate Testing for Children
with Pharyngitis
(5/3,431) x (2/28.3)
0.0001029895
0.0001029895 /
0.0359536258
0.0028645087
0.0028645087 /
$8,769.75
$25.12
Appropriate Testing for Children
with Upper Respiratory Infection
(5/3,431) x
(1/28.3)
0.0000514947
0.0000514947 /
0.0359536258
0.0014322544
0.0014322544 /
$8,769.75
$12.56
Body Mass Index Assessment
(600/3,431) x
(.15/28.3)
0.0009269053
0.0009269053 /
0.0359536258
0.0257805786
0.0257805786 /
$8,769.75
$226.09
Breast Cancer Screening
(453/3,431) x
(1/28.3)
0.0046654232
0.0046654232 /
0.0359536258
0.1297622450
0.1297622450 /
$8,769.75
$1,137.98
Cervical Cancer Screening
(671/3,431) x
(1/28.3)
0.0069105938
0.0069105938 /
0.0359536258
0.1922085362
0.1922085362 /
$8,769.75
$1,685.62
Childhood Immunization Status
(4/3,431) x
(4/28.3)
0.0001647832
0.0001647832 /
0.0359536258
0.0045832140
0.0045832140 /
$8,769.75
$40.19
Chlamydia Screening for Women
(16/3,431) x
(1/28.3)
0.0001647832
0.0001647832 /
0.0359536258
0.0045832140
0.0045832140 /
$8,769.75
$40.19
Colorectal Cancer Screening
(756/3,431) x
(1/28.3)
0.0077860043
0.0077860043 /
0.0359536258
0.2165568605
0.2165568605 /
$8,769.75
$1,899.15
Comprehensive Diabetes Care –
Blood Pressure Control (<140/90)
(92/3,431) x
(2/28.3)
0.0018950063
0.0018950063 /
0.0359536258
0.0527069608
0.0527069608 /
$8,769.75
$462.23
Comprehensive Diabetes Care –
Eye Exam
(92/3,431) x
(1/28.3)
0.0009475032
0.0009475032 /
0.0359536258
0.0263534804
0.0263534804 /
$8,769.75
$231.11
Comprehensive Diabetes Care –
HbA1c Control (< 8.0)
(92/3,431) x
(2/28.3)
0.0018950063
0.0018950063 /
0.0359536258
0.0527069608
0.0527069608 /
$8,769.75
$462.23
Comprehensive Diabetes Care –
Medical Attention for Nephropathy
(92/3,431) x
(1/28.3)
0.0009475032
0.0009475032 /
0.0359536258
0.0263534804
0.0263534804 /
$8,769.75
$231.11
Controlling Blood Pressure
(420/3,431) x
(2/28.3)
0.0086511159
0.0086511159 /
0.0359536258
0.2406187339
0.2406187339 /
$8,769.75
$2,110.17
Immunizations for Adolescents
(11/3,431) x
(1/28.3)
0.0001132884
0.0001132884 /
0.0359536258
0.0031509590
0.0031509590 /
$8,769.75
$27.63
Medication Management for People
with Asthma (75% Compliance)
(10/3,431) x
(3/28.3)
0.0003089684
0.0003089684 /
0.0359536258
0.0085935262
0.0085935262 /
$8,769.75
$75.36
Weight Assessment and Counseling for Nutrition and Physical
Activity for Children / Adolescents
(100/3,431) x
(.15/28.3)
0.0001544842
0.0001544842 /
0.0359536258
0.0042967631
0.0042967631 /
$8,769.75
$37.68
Well-Child Visits in the First 15
months of Life
(2/3,431) x
(3/28.3)
0.0000617937
0.0000617937 /
0.0359536258
0.0017187052
0.0017187052 /
$8,769.75
$15.07
Well-Child Visits in the Third,
Fourth, Fifth, and Sixth years of Life
(10/3,431) x
(2/28.3)
0.0002059790
0.0002059790 /
0.0359536258
0.0057290175
0.0057290175 /
$8,769.75
$50.24
MEASURES
TOTAL
0.0359536258
29
NORMALIZED
WEIGHT
CALCULATION
(COMBINED
WEIGHT/
TOTAL
COMBINED
WEIGHT)
NORMALIZED
WEIGHT
MAX
PAYMENT
$8,769.75
QUEST Integration Quality Scoring Calculations
Step 2: Performance and Improvement Points Earned
QUEST INTEGRATION
To calculate performance and improvement points and the
portion of the Max Payment that will be earned for each measure,
follow these steps. The figures below use numbers from
measures on Dr. Lee’s 2016 Quest Integration Performance
Quality Report example.
a.Determine the performance level than the current performance rate falls into (the level at which the performance rate
is greater than or equal to, but less than the next highest
percentile level) See the National Percentile Threshold Rates
Table, page 32.
Example:
For the breast cancer measure, Dr. Lee’s performance rate
is 77.26 percent. The performance rate of 77.26 percent is
above the 90th percentile (73.35 percent). The breast cancer
performance rate is in the 90th percentile.
b.The baseline percentile, along with the current percentile, is
used to determine the performance and improvement points.
(See Performance and Improvement Points by Performance
Level Tables, pages 33-34.)
Example:
Dr. Lee's breast cancer screening baseline percentile was in
the 90th percentile. Dr. Lee’s current performance percentile
for breast cancer screening is in the 90th percentile.
Using the Performance and Improvement Points by
Percentile Range Tables, Dr. Lee earned 10 performance
points and 2.5 improvement points for a total of 12.5 points.
30
QUEST Integration Quality Scoring Calculations
Step 3: Calculation of Actual Payment Earned for Each Measure
QUEST INTEGRATION
Multiply the maximum payment for each measure by the total
points earned. Divide the result by 10 to determine the actual
payment earned for each measure.
Example:
Dr. Lee’s maximum payment for breast cancer screening is
$1,137.98. Dr. Lee earned 12.5 total points for the breast
cancer screening measure. Dr. Lee’s actual payment earned
for the breast cancer screening measure is ($1,137.98 x 12.5
points) / 10 = $1,422.48.
Each measure has a budget of 10 performance points. A provider
may exceed the performance points by earning bonus points on
individual measures. The total payment earned amount (total of
all payments earned for all measures) is capped at 110 percent of
the total maximum payment potential.
Providers must score at least 40 percent overall in each program
(Commercial, QUEST Integration, and HMSA Akamai Advantage)
to qualify for payment in the respective line of business. For
example, if a provider scores 82 percent overall in Commercial
and 31 percent overall in QUEST Integration, the provider will be
awarded earned dollars for Commercial, but will not be awarded
earned dollars for QUEST Integration.
31
QUEST INTEGRATION
National Percentile Threshold Rates – Clinical Measures†
Threshold Scale Selection
QUEST INTEGRATION MEASURES
10TH
25TH
50TH
75TH
90TH
Appropriate Testing for Children with
Pharyngitis
51.84
61.82
71.30
79.97
87.09
Appropriate Testing for Children with
Upper Respiratory Infection
78.03
82.57
87.11
93.21
96.39
Body Mass Index Assessment
65.35
72.54
79.81
87.23
92.82
Breast Cancer Screening
47.59
52.21
58.37
67.12
73.35
Cervical Cancer Screening
48.22
60.15
67.42
73.96
78.64
Childhood Immunization Status
(All individual immunizations)
66.97
71.60
77.89
83.74
87.40
Chlamydia Screening for Women
48.62
53.70
59.40
65.89
70.83
Colorectal Cancer Screening
50.56
60.95
68.16
74.41
78.24
Comprehensive Diabetes Care –
Blood Pressure Control
48.02
55.48
64.50
72.07
77.44
Comprehensive Diabetes Care – Eye Exam
38.23
47.25
55.31
65.14
70.04
Comprehensive Diabetes Care – HbA1c
Control (≤8)
36.04
43.09
49.72
57.7
61.37
Comprehensive Diabetes Care –
Medical Attention for Nephropathy
72.43
76.67
81.05
85.11
88.86
Controlling Blood Pressure
45.90
51.33
58.52
65.76
71.79
Immunizations for Adolescents
(All individual immunizations)
54.94
62.70
72.29
82.90
88.46
Medication Management for People with
Asthma
21.00
25.55
31.16
36.96
44.79
Weight Assessment and Counseling for
Nutrition and Physical Activity for Children/
Adolescents
38.69
49.14
60.85
71.76
78.90
Well-Child Visits in the First 15 months
of Life
50.70
56.95
66.16
72.90
79.44
Well-Child Visits in the Third, Fourth, Fifth,
and Sixth years of life
61.81
68.40
73.26
80.51
84.69
† Percentile ranks reflect the provider network performance for a large number of health plans (actual numbers vary by measure).
These percentile levels are from NCQA Quality Compass®.
Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).
32
QUEST INTEGRATION
Performance and Improvement Points by Performance Level Tables
The following tables correspond to the six possible Baseline Period Performance levels and detail the performance and improvement
points earned based on current measurement period performance. Select the table that corresponds to your baseline performance
level for each measure. Locate the row that describes your current-period performance percentile level and note the total points
earned for each measure.
Table 1: Baseline Period Performance: < 10th Percentile
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
2
2
25 percentile
0
3
3
50th percentile
4
2
6
75 percentile
8
2.5
10.5
10
2.5
12.5
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
th
th
th
90 percentile
th
Table 2: Baseline Period Performance: 10 Percentile
th
MEASUREMENT PERIOD PERFORMANCE
<10th percentile
0
0
0
10th percentile
0
0
0
25th percentile
0
2
2
50 percentile
4
2
6
75 percentile
8
2.5
10.5
10
2.5
12.5
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
th
th
90 percentile
th
Table 3: Baseline Period Performance: 25 Percentile
th
MEASUREMENT PERIOD PERFORMANCE
<10th percentile
0
0
0
10th percentile
0
0
0
25th percentile
0
0
0
50 percentile
4
2
6
75 percentile
8
2.5
10.5
90th percentile
10
2.5
12.5
th
th
33
QUEST INTEGRATION
Table 4: Baseline Period Performance: 50th Percentile
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
0
0
25 percentile
0
0
0
50 percentile
4
0
4
75th percentile
8
2.5
10.5
90th percentile
10
2.5
12.5
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
IMPROVEMENT
POINTS
TOTAL POINTS
<10th percentile
0
0
0
th
th
th
Table 5: Baseline Period Performance: 75th Percentile
10 percentile
0
0
0
25th percentile
0
0
0
50 percentile
4
0
4
75 percentile
8
0
8
90 percentile
10
2.5
12.5
MEASUREMENT PERIOD PERFORMANCE
PERFORMANCE
POINTS
SUSTAINED
EXCELLENCE
TOTAL POINTS
<10th percentile
0
0
0
10 percentile
0
0
0
25 percentile
0
0
0
50 percentile
4
0
4
75th percentile
8
0
8
90 percentile
10
2.5
12.5
th
th
th
th
Table 6: Baseline Period Performance: 90th Percentile
th
th
th
th
34
HMSA Akamai Advantage Quality Scoring Calculations
HMSA Akamai Advantage
Maximum Payment Potential
HMSA Akamai Advantage
Your actual monthly maximum payment potential for a measure
may vary each month as the number of eligible members varies
based on several factors, including enrollment, PCP selection,
chronic conditions, and treatments. The calculation process will
be repeated every month to determine your actual yearly
maximum payment potential.
The health status of individual HMSA Akamai Advantage
members varies widely. You may have more patients with chronic
diseases or comorbidities and therefore have more challenges in
keeping your patients healthy. To align pay-for-quality
payments with the unique number of care opportunities for your
practice, the program counts the number of members in your
primary care panel who meet the criteria for each measure each
month (the patient panel count). This number is multiplied by a
PMPM amount to calculate your monthly maximum payment
potential for each measure. PMPM amounts are based on the
approximate relative value of each measure for the current
measurement period.
Below is an example of the estimated yearly maximum payment
potential for one PCP based on one month.
DENOMINATOR
PMPM
MONTHLY
MAXIMUM PAYMENT
POTENTIAL
EST. YEARLY
MAXIMUM PAYMENT
POTENTIAL
Advance Care Planning
38
$2.00
$76.00
$912.00
Body Mass Index Assessment
56
$0.25
$14.00
$168.00
Breast Cancer Screening
13
$1.00
$13.00
$156.00
Colorectal Cancer Screening
56
$1.00
$56.00
$672.00
Comprehensive Diabetes Care –
Blood Pressure Controlled
24
$2.00
$48.00
$576.00
Comprehensive Diabetes Care –
Eye Exam
24
$1.00
$24.00
$288.00
Comprehensive Diabetes Care –
HbA1c Control (≤9%)
24
$2.00
$48.00
$576.00
Comprehensive Diabetes Care –
Medical Attention for Nephropathy
24
$1.00
$24.00
$288.00
Controlling Blood Pressure
54
$2.00
$108.00
$1,296.00
Medication Adherence for
Cholesterol (Statins)
94
$1.50
$141.00
$1,692.00
Medication Adherence
for Hypertension (RAS Antagonist)
44
$1.50
$66.00
$792.00
Medication Adherence for
Oral Diabetes Medications
38
$1.50
$57.00
$684.00
Review of Chronic Conditions
128
$6.50
$832.00
$7,488.00
$1,507.00
$15,588.00
MEASURE
TOTAL
Note that RCC is a nine month pay potential instead of 12 months.
35
HMSA Akamai Advantage Quality Scoring Calculations
Example Performance Quality Report
HMSA AKAMAI ADVANTAGE
To work through the following examples, consult the 2016 Performance Quality Report for Dr. Aloha Lee below.
Performance Period:
Baseline Period: Provider:
1/1/2016 to 12/31/2016
1/1/2015 to 12/31/2015
LEE, ALOHA
Est. Eligible Members: 580
Maximum Payment Potential: $15,588
DEMONINATOR
NUMERATOR
PERFORMANCE
RATE
BASELINE
STARS
EARNED
PERFORMANCE
STARS
EARNED
Advance Care Planning
38
17
44.74%
3
Body Mass Index Assessment
56
53
94.64%
Breast Cancer
13
12
Colorectal Cancer
56
Comprehensive Diabetes Care –
Blood Pressure Control < 140/90
PERFORMANCE
POINTS
PMPM
2
0
$2.00
$912
$0
3
2
0
$0.25
$168
$0
92.31%
3
5
12.5
$1.00
$156
$195
46
82.14%
5
5
12.5
$1.00
$672
$840
24
15
62.50%
2
2
0
$2.00
$576
$0
Comprehensive Diabetes Care –
Eye Exam
24
20
83.33%
4
4
8
$1.00
$288
$230.40
Comprehensive Diabetes Care –
HbA1c Control (≤9)
24
20
83.33%
3
3
4
$2.00
$576
$230.40
Comprehensive Diabetes Care –
Nephropathy
24
24
100%
5
5
12.5
$1.00
$288
$360
Controlling Blood Pressure
54
41
75.93%
4
3
4
$2.00
$1,296
$518.40
Medication Adherence – Cholesterol
(Statins)
94
82
87.23%
5
5
12.5
$1.50
$1,692
$2,115
Medication Adherence –
Hypertension (RAS Antagonist)
44
39
88.64%
5
5
12.5
$1.50
$792
$990
Medication Adherence –
Oral Diabetes Medications
38
35
92.11%
4
5
12.5
$1.50
$684
$855
Review of Chronic Conditions=
128
118
92.19%
4
4
8
$6.50
$7,488
$5,990.40
TOTAL
617
MAX
PAYMENT
PAYMENT
EARNED
$15,588 $12,324.60
Earned RCC Adjuster:
100%
Earned Total Quality Payment:
$12,324.60
= The
denominator and numerator counts for the review of chronic conditions measure is based on the number of conditions rather
than patient panel count.
36
HMSA Akamai Advantage Quality Scoring Calculations
Step 1: Calculation of Maximum Payment for Each Measure
HMSA AKAMAI ADVANTAGE
To calculate monthly maximum payment potential for each measure, multiply the number of patients eligible for each measure
(denominator) by the designated PMPM. Repeat this calculation
every month to determine your yearly maximum payment potential for each measure.
Example:
Dr. Lee’s breast cancer denominator is 13 patients. The breast
cancer PMPM is $1.00. The monthly maximum payment
potential for Dr. Lee’s breast cancer measure is $13.00.
The yearly maximum payment for Dr. Lee’s breast cancer
measure is $156.00 (13 patients x $1 PMPM x 12 months).
Please note that monthly eligibitly may vary, see page 36 for
more details.
†
Patients in the review of chronic conditions measure won’t contribute to the maximum payment potential for the entire measurement
period if:
• You didn’t provide services to and/or submit a claim for the patient during the measurement period.
• The patient did not have any chronic conditions in the measure denominator after scoring adjustments at the end of the
measurement period.
37
HMSA Akamai Advantage Quality Scoring Calculations
Step 2: Performance and Improvement Points Earned
HMSA AKAMAI ADVANTAGE
To calculate performance and improvement points and the
portion of the max payment that will be earned for each measure,
follow these steps.
a.Determine the performance level that the current performance rate falls into (the level at which the performance rate
is greater than or equal to, but less than the next highest
percentile level). See the National Percentile Threshold Rates
Table, page 40.
Example:
For the breast cancer measure, Dr. Lee’s performance rate
is 92.31 percent. The performance rate of 92.31 percent is
above the five star rate (85 percent). The breast cancer
performance rate is in the five star level.
b.The baseline stars earned, along with the current stars
earned, is used to determine the performance and improvement points. (See Performance and Improvement Points by
Performance Level Tables, pages 41-42.)
Example:
Dr. Lee's breast cancer screening baseline stars earned was
five stars. Dr. Lee’s current breast cancer screening stars
earned is five stars. Using the Performance and Improvement Points by Performance Level Tables, (page 41), Dr. Lee
earned 10 performance points and 2.5 improvement points
for a total of 12.5 points.
38
HMSA Akamai Advantage Quality Scoring Calculations
Step 3: Calculation of Actual Payment Earned for Each Measure
HMSA AKAMAI ADVANTAGE
Multiply the maximum payment for each measure by the total
points earned. Divide the result by 10 to determine the actual
payment earned for each measure.
Example:
Dr. Lee’s maximum payment for breast cancer screening is
$156. Dr. Lee earned 12.5 total points for the breast cancer
screening measure. Dr. Lee's actual payment earned for the
breast cancer screening measure is $195 ($156 x 12.5) / 10.
Each measure has a budget of 10 performance points.
A provider may exceed the performance points by earning bonus
points on individual measures. The total payment earned amount
(sum of all payments earned for all measures) is capped at
110 percent of the total maximum payment potential.
Providers must score at least 40 percent overall in each program
(Commercial, QUEST Integration, and HMSA Akamai Advantage)
to qualify for payment in the respective line of business. For
example, if a provider scores 82 percent overall in Commercial
and 31 percent overall in QUEST Integration, the provider will be
awarded earned dollars for Commercial, but will not be awarded
earned dollars for QUEST Integration.
39
HMSA AKAMAI ADVANTAGE
National Percentile Threshold Rates
HMSA Akamai Advantage Primary Care Pay-for-Quality Clinical Measures
National percentile threshold rates are based on National Committee for Quality Assurance (NCQA) HEDIS and CMS Medicare
Advantage Stars program performance levels.
ONE
STAR
TWO
STARS
THREE
STARS
FOUR
STARS
FIVE
STARS
Advance Care Planning
30.00%
40.00%
50.00%
60.00%
70.00%
Body Mass Index Assessment
86.32%
91.19%
94.90 %
97.14%
98.70%
Breast Cancer Screening
59.42%
66.57%
72.41%
80.27%
85.00%
Colorectal Cancer Screening
51.00%
57.84%
66.45%
73.53%
79.86%
Comprehensive Diabetes Care – Blood Pressure Control
(<140/90)
55.50%
60.12%
67.06%
75.24%
82.33%
Comprehensive Diabetes Care – Eye Exam
56.79%
64.50%
70.84%
78.83%
84.69%
Comprehensive Diabetes Care – HbA1c Control (≤ 9.0)
58.18%
69.52%
78.76%
86.89%
91.69%
Comprehensive Diabetes Care – Medical Attention for
Nephropathy
87.43%
90.05%
92.31%
95.92%
98.11%
Controlling Blood Pressure
53.22%
63.23%
73.32%
79.15%
83.52%
Medication Adherence – Cholesterol (Statins)
47.95%
64.00%
69.40%
78.00%
85.00%
Medication Adherence – Hypertension (RAS Antagonist)
51.48%
73.00%
77.00%
83.00%
87.00%
Medication Adherence – Oral Diabetes Medications
52.30%
70.00%
74.00%
79.00%
83.00%
Review of Chronic Conditions
60.00%
70.00%
80.00%
90.00%
95.00%
HMSA AKAMAI ADVANTAGE MEASURE
40
HMSA AKAMAI ADVANTAGE
Performance and Improvement Points by Performance Level Tables
The following tables correspond to the six baseline period ranges and detail the performance and improvement points earned based
on current measurement period performance. Select the table that corresponds to your baseline performance level for each measure.
Locate the row that describes your current-period star level and note the total points earned for each measure.
Table 1: Prior-Period Performance: Below One-Star Level
CURRENT-PERIOD
PERFORMANCE
PERFORMANCE POINTS
IMPROVEMENT POINTS
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
2
2
Two-star level
0
3
3
Three-star level
4
2
6
Four-star level
8
2.5
10.5
Five-star level
10
2.5
12.5
PERFORMANCE POINTS
IMPROVEMENT POINTS
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
0
0
Two-star level
0
2
2
Three-star level
4
2
6
Four-star level
8
2.5
10.5
Five-star level
10
2.5
12.5
PERFORMANCE POINTS
IMPROVEMENT POINTS
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
0
0
Two-star level
0
0
0
Three-star level
4
2
6
Four-star level
8
2.5
10.5
Five-star level
10
2.5
12.5
Table 2: Prior-Period Performance: One-Star Level
CURRENT-PERIOD
PERFORMANCE
Table 3: Prior-Period Performance: Two-Star Level
CURRENT-PERIOD
PERFORMANCE
41
HMSA AKAMAI ADVANTAGE
Table 4: Prior-Period Performance: Three-Star Level
CURRENT-PERIOD
PERFORMANCE
PERFORMANCE POINTS
IMPROVEMENT POINTS
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
0
0
Two-star level
0
0
0
Three-star level
4
0
4
Four-star level
8
2.5
10.5
Five-star level
10
2.5
12.5
PERFORMANCE POINTS
IMPROVEMENT POINTS
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
0
0
Two-star level
0
0
0
Three-star level
4
0
4
Table 5: Prior-Period Performance: Four-Star Level
CURRENT-PERIOD
PERFORMANCE
Four-star level
8
0
8
Five-star level
10
2.5
12.5
PERFORMANCE POINTS
SUSTAINED EXCELLENCE
TOTAL POINTS
Below one-star level
0
0
0
One-star level
0
0
0
Two-star level
0
0
0
Three-star level
4
0
4
Four-star level
8
0
8
Five-star level
10
2.5
12.5
Table 6: Prior-Period Performance: Five-Star Level
CURRENT-PERIOD
PERFORMANCE
42
HMSA Akamai Advantage Quality Scoring Calculations
Step 4: Application of the RCC Adjuster
HMSA AKAMAI ADVANTAGE
Step 4: Application of the
RCC Adjuster
To calculate the final payment, the performance period rate
for the review of chonic conditions measure will be used as an
adjuster.
a.Using the RCC measure performance rate, refer to the table
below to determine your performance adjuster.
RCC Measure Performance Adjuster
RCC PERFORMANCE
RATE
ADJUSTMENT RATE
<60.00%
0%
60.00%–69.99%
75%
≥70.00%
100%
Examples:
For the RCC measure, Dr. Lee’s performance rate was
92 percent. The RCC adjuster rate for Dr. Lee is 100 percent.
b.To calculate Earned Total Quality Payment, multiply the
RCC adjuster rate by the total of all payments earned for all
measures.
Examples:
Dr. Lee’s RRC adjuster rate was 100 percent. Dr. Lee's total
payment earned was $12,324.60. Dr Lee's earned total
quality payment is $12,324.60 (100 percent x $12,324.60).
43
Report Definition
REPORT TERMS USED
TERM DEFINITION
Performance Period
The past one year period of measurement for the current report.
Baseline Period
The measure period one year before the performance period of the current
report.
Estimated member months
The number of eligible patients in the PCP's primary care panel at the end of
each month. Sum each month’s eligible panel count for each month within
the quarter. Max Payment
Refers to each measure's maximum payment. Please see performance scoring
calculation steps. The measure’s maximum earn potential without improvement
points. With improvement points, the PCP may earn more than the max payment.
Total Max Pay Potential (Commercial and
QUEST Integration only)
The quarter’s member months multiplied by $4.25 (Commercial) or $2.75
(QUEST Integration). The Payment Earned will be capped at 110 percent of Total
Max Payment.
Total Max Pay Potential (HMSA Akamai Advantage only)
The sum of all measure max quality payments.
Measure Weight (Commercial and QUEST Integration only)
The degree of difficulty required to complete the clinical process for each
measure and the importance of the measure to HMSA's accreditation ranking
and/or regulatory requirements.
Denominator
All the patients of a PCP that the measure definition applies to during the
performance period.
Numerator
All the patients of a PCP who achieved the measures definition of attainment.
Performance Rate
Divide the numerator by the denominator.
Percentile
The percentile group the PCP falls into based on current period performance. Using the measure performance rate, refer to the line of business threshold
tables found in the Pay-for-Quality Guide to identify the percentile achieved. Baseline Percentile
The percentile group the PCP falls in based on baseline period performance. Using the measure performance rate of the baseline period, the Pay for
Quality Guide of the baseline year to identify the percentile achieved in the
baseline period. Points
The number of points earned based on performance in the baseline and current
performance periods. Using the baseline percentile and current performance
percentile, refer to the line of business point tables found in the Pay for Quality
Guide to identify the points assigned to those levels of measure achievement. Payment Earned (HMSA Akamai Advantage only)
For most measures, multiply the denominator by 12 months. Multiply the result
by the PMPM of the measure. For the RCC measure, multiply the denominator by
nine months. Multiply the RCC result by the RCC PMPM.
Payment Earned (Commercial and QUEST Integration)
For each measure, multiply the estimated maximum payment by the points
earned. Divide the result by 10.
44
Appendix A - Pay-for-Quality Measure Detail
Find the clinical measures indexed alphabetically below.
• • • Advance Care Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
• • • Appropriate Testing for Children with Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
• • • Appropriate Treatment for Children with Upper Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
• • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• • • Body Mass Index Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
• • • Breast Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
• • • Cervical Cancer Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
• • • Childhood Immunization Status (All individual immunizations). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
• • • Chlamydia Screening for Women. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
• • • Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
• • • Comprehensive Diabetes Care – Blood Pressure Control (<140/90) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
• • • Comprehensive Diabetes Care – Eye Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
• • • Comprehensive Diabetes Care – HbA1c Control (<8.0%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
• • • Comprehensive Diabetes Care – HbA1c In Control (≤9%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
• • • Comprehensive Diabetes Care – Medical Attention for Nephropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
• • • Controlling Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
• • • Immunizations for Adolescents (All individual immunizations). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
• Medication Adherence for Cholesterol (Statins). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
• Medication Adherence for Hypertension (RAS Antagonist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
• Medication Adherence for Oral Diabetes Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
• • • Medication Management for People with Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
• • • Review of Chronic Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
• • • Well-Child Visits in the First 15 Months of Life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
• • • Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
• • • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents. . . . . . . . . . . 73
• COMMERCIAL
INTEGRATION
• QUEST
• HMSA AKAMAI ADVANTAGE
45
Primary Care Measures
Advance Care Planning
COMMERCIAL • HMSA AKAMAI ADVANTAGE
Description
The percentage of patients 75 years of age and older at the end
of the measurement period who had an advance care plan and/or
an advance care planning discussion with their PCP documented
during the measurement period.
iv. Comfort care option.
v. Advance directive decisions.
vi.Durable power of attorney for health care/designated
surrogate.
vii. The patient’s key questions for further discussion.
viii. The progression of their illness.
Numerator
Advance care discussion or plan documented in the medical
record and a CPT code submitted during the measurement
period.
ix. Potential complications.
x.Specific life-sustaining treatments that may be required
if their illness progresses.
Acceptable documentation:
1. Examples of an advance care plan:
d.If your patient can't participate in the conversation (e.g.,
patient has Alzheimer's or isn't legally capable to make
decisions), you should document the patient’s status.
Providers can submit either through a CPT code submitted
during the measurement period or supplemental data with
documentation upload.
a.
Advance directive. Directive about treatment preferences
and the designation of a surrogate who can make medical
decisions for a patient who is unable to make them
(e.g., living will, power of attorney, health care proxy).
Please click the icon below for allowable numerator codes:
b.
Actionable medical orders. Written instructions regarding
initiating, continuing, withholding, or withdrawing specific
forms of life-sustaining treatment (e.g., Physician Orders
for Life Sustaining Treatment [POLST], Five Wishes).
Denominator
COMMERCIAL
c.
Living will. Legal document denoting preferences for
life-sustaining treatment and end-of-life care.
Patients 75 years of age and older at the end of the measure
period.
d.
Surrogate decision maker. A written document designating someone other than the member to make future medical treatment choices.
HMSA AKAMAI ADVANTAGE
Patients 75 years of age and older at the end of the measurement
period.
Executed documents completed by another provider (e.g., upon
discharge) can be used to fulfill numerator criteria as long as there
was evidence of review and validation of the content in the
medical record.
Exclusions
Please click the icon below for allowable exclusion codes:
2. Examples of an advance care planning discussion:
a.Notation in the medical record of a discussion with a
provider or initiation of a discussion by a provider during
the measurement year.
Supplemental Data Option Documentation
Requirements
b. Conversations with relatives or friends about life-sustaining
treatment and end-of-life care, documented in the medical record. Patient designation of an individual who can
make decisions on behalf of the patient. Evidence of oral
statements must be noted in the medical record during the
measurement year.
To attest that a patient has an advance care plan or has had an
advance care planning discussion, submit acceptable documentation (listed in the numerator).
Supporting medical record documentation must be uploaded into
Cozeva before the supplemental data will be accepted
and scored.
c.If your patient is uncomfortable or not ready to create an
advance care plan document, the patient’s chart should
document the patient’s current thinking about at least one
of the following:
i.CPR.
ii.Goals of care for cardiopulmonary failure,
including hospitalization.
iii. Artificial nutrition and hydration.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
46
Appropriate Testing for
Children with Pharyngitis
Appropriate Treatment for Children
with Upper Respiratory Infection
COMMERCIAL • QUEST INTEGRATION
COMMERCIAL • QUEST INTEGRATION
Description
Description
Percentage of patients 2–18 years of age who were diagnosed
with pharyngitis, prescribed an antibiotic, and received a group
A streptococcus test for the episode. This measure is largely
consistent with the Institute for Clinical Systems Improvement’s
Health Care Guideline for the Diagnosis and Treatment of
Respiratory Illness in Children and Adults
(icsi.org/_asset/1wp8x2/RespIllness.pdf).
Percentage of children 3 months to 18 years of age who were
given a diagnosis of upper respiratory infection (URI) and weren’t
dispensed an antibiotic prescription on or three days after the
episode date. This measure is largely consistent with the Institute
for Clinical Systems Improvement’s Health Care Guideline for the
Diagnosis and Treatment of Respiratory Illness in Children and
Adults (icsi.org/_asset/1wp8x2/RespIllness.pdf).
Numerator
Numerator
A strep test administered in the seven-day period from three
days prior through three days after the first eligible episode date.
Codes* to identify group A streptococcus tests antigen detection:
Patients who weren’t dispensed a prescription for antibiotic
medication by their attributed PCP on or within three days after
the episode date.
Please click the icon below for allowable numerator codes:
Please click the icon below for allowable numerator codes:
Denominator
Denominator
Children 2 years of age as of the 183rd day of the prior measurement period to 18 years of age as of the 182nd day of the
measurement period who had only a diagnosis of pharyngitis and
a dispensed antibiotic for that episode of care by their attributed
PCP visit during the intake period.
All children age 3 months as of the 183rd day of the prior
measurement period to 18 years as of the 182nd day of the
measurement period who were diagnosed with non-specific URI
by their attributed PCP.
Please click the icon below for allowable denominator codes:
Exclusions
Exclusions
Exclude episode dates where the patient had a claim/
encounter with a competing diagnosis (below) on or three days
after the episode date.
Please click the icon below for allowable exclusion codes:
Please click the icon below for allowable exclusion codes:
Supplemental Data Option Documentation
Requirements
Supplemental Data Option Documentation
Requirements
Supplemental data won’t be accepted for this measure.
Supplemental data won’t be accepted for this measure.
Measure Status
NQF # 0002
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Measure Status
NQF # 0069
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
**Don't include Emergency Department visits that result in an inpatient admission.
47
Avoidance of Antibiotic Treatment
in Adults with Acute Bronchitis
COMMERCIAL
Description
Percentage of adult patients 18–64 years of age who were
diagnosed with acute bronchitis and weren't dispensed an
antibiotic prescription. The measure is reported as an inverted
rate [1-(numerator/denominator)]. A higher rate indicates
appropriate treatment (i.e., the proportion for whom antibiotics
weren’t prescribed).
Numerator
Patients in the denominator who were prescribed an antibiotic by
their attributed PCP on or within three days after the date
of service (see antibiotic medication list on page 49).
Denominator
All patients 18 years of age as of the first day of the prior
measurement period to 64 years of age as of the last day of
the current measurement period who had a diagnosis of acute
bronchitis by their attributed PCP on or between the first and the
348th day of the measurement period.
This measure examines the earliest eligible episode per patient.
Please click the icon below for allowable denominator codes:
Exclusions
1.Any date of service with a principal or secondary diagnosis for
a comorbid condition (see link) during the 12 months prior to
and including the episode date.
2.Any date of service with a competing diagnosis (see link)
during the period 30 days prior to the date of service through
seven days after the episode date (inclusive).
3.Any date of service that meets these criteria:
• No pharmacy claims for either new or refill prescriptions for
any of the listed antibiotic drugs (see link) during the
30-day period prior to the episode date.
• No prescriptions were filled more than 30 days before and
weren't active on the episode date.
Note:
• A
prescription is considered active if the “days supply”
indicated on the date when the patient filled the
prescription is the number of days or more between
that date and the relevant service date.
• T
he 30-day look-back period for pharmacy data includes
the 30 days before the first day of the measurement period.
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
48
Antibiotic Medications
DESCRIPTION
PRESCRIPTION
Aminoglycosides
Amikacin, Gentamicin, Kanamycin, Streptomycin, Tobramycin
Aminopenicillins
Amoxicillin, Ampicillin
Antipseudomonal penicillins
Piperacillin
Beta-lactamase inhibitors
Amoxicillin-clavulanate, Ampicillin-sulbactam, Piperacillin-tazobactam, Ticarcillin-clavulanate
First-generation cephalosporins
Cefadroxil, Cefazolin, Cephalexin
Fourth-generation cephalosporins
Cefepime
Ketolides
Telithromycin
Lincomycin derivatives
Clindamycin, Lincomycin
Macrolides
Azithromycin, Clarithromycin, Erythromycin, Erythromycin ethylsuccinate, Erythromycin lactobionate,
Erythromycin stearate
Miscellaneous antibiotics
Aztreonam, Chloramphenicol, Dalfopristin-quinupristin, Daptomycin, Erythromycin-sulfisoxazole, Linezolid,
Metronidazole, Vancomycin
Natural penicillins
Penicillin G benzathine-procaine, Penicillin G potassium, Penicillin G procaine, Penicillin G sodium,
Penicillin V potassium, Penicillin G benzathine
Penicillinase resistant penicillins
Dicloxacillin, Nafcillin, Oxacillin
Quinolones
Ciprofloxacin, Gemifloxacin, Levofloxacin, Moxifloxacin, Norfloxacin, Ofloxacin
Rifamycin derivatives
Rifampin
Second generation cephalosporins Cefaclor, Cefotetan, Cefoxitin, Cefprozil, Cefuroxime
Sulfonamides
Sulfadiazine, Sulfamethoxazole-trimethoprim
Tetracyclines
Doxycycline, Minocycline, Tetracycline
Third generation cephalosporins
Cefdinir, Cefditoren, Cefixime, Cefotaxime, Cefpodoxime, Ceftazidime, Ceftibuten, Ceftriaxone
Urinary anti-infectives
Fosfomycin, Nitrofurantoin, Nitrofurantoin macrocrystals, Nitrofurantoin macrocrystals-monohydrate,
Trimethoprim
Supplemental Data Option Documentation Requirements
Supplemental data won't be accepted for this measure.
Measure Status
NQF # 0058
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
49
Body Mass Index Assessment
Supplemental Data Option Documentation
Requirements
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
To attest that the BMI assessment was performed, medical
record evidence of the following is required:
Description
For members younger than 21 years on the date of service,
documentation in the medical record must indicate the height,
weight, and BMI percentile, dated during the measurement year
or year prior to the measurement year. The height, weight, and
BMI percentile must be from the same data source.
The percentage of patients 18-74 years of age who had an
outpatient visit and whose body mass index (BMI) was
documented during the measurement period.
Numerator
For BMI percentile, the following documentation meets criteria:
The number of patients whose BMI was reported either through
claims or through supplemental data. For claims, use the
following codes, which indicate numerator compliance for
this measure.
• BMI percentile documented as a value (e.g., 85th percentile).
• BMI percentile plotted on an age-growth chart.
• For patients 18–20 years of age: BMI percentile plotted on an
age growth chart OR medical note that indicates the date that
the BMI assessment was performed and the BMI value along
with weight documented in the same record during the
measurement period.
Please click the icon below for allowable numerator codes:
Denominator
For patients 21+ years of age: Medical note that indicates the
date the BMI assessment was performed and the value along
with weight documented in the same record during the
measurement period.
COMMERCIAL • QUEST INTEGRATION
Patients 18-74 years of age who had an outpatient visit during
the measurement period.
You must upload supporting medical record documentation
to Cozeva before the supplemental data will be accepted
and scored.
Please click the icon below for allowable denominator codes:
HMSA AKAMAI ADVANTAGE
Note: A distinct BMI value or percentile, if applicable, is required
to meet the criteria of the numerator.
Patients 18-74 years of age who had an outpatient visit during
the measurement period.
Documentation Requirements for Request
for Reconsideration
Exclusions
To attest that a patient should be excluded, medical record
evidence of the following is required.
Patients who have a diagnosis of pregnancy during the
measurement period.
• A note indicating diagnosis of pregnancy during the
measurement period.
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
50
Breast Cancer Screening
Supplemental Data Option Documentation
Requirements
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
To attest that a breast cancer screening was performed, medical
record evidence of the following is required:
Description
• Mammogram – one or more mammograms within the measurement period of the 15 months prior to the measurement period.
The percentage of women 52–74 years of age as of the end of
the measurement period who had one or more mammograms to
screen for breast cancer during the measurement period or the
15 months prior to the measurement period. The purpose of this
measure is to evaluate primary screening; claims for biopsies,
breast ultrasounds, or MRIs won't count toward this measure
because they aren’t considered appropriate methods for
primary breast cancer screening. This measure currently follows
2002 recommendations from the U.S. Preventive Services Task
Force (USPSTF) (uspreventiveservicestaskforce.org/Page/Topic/
recommendation-summary/breast-cancer-screening).
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence of one of the following is required:
• Bilateral mastectomy – operative note indicating the date that a
bilateral mastectomy was completed.
• Unilateral mastectomy – operative note indicating two different
occurrences on two different dates of service that are 14 days
or more apart from each other.
Numerator
Measure Status
Patients who had one or more mammograms performed during
the measurement period or the 15 months prior to the measurement period.
NQF # 0031
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
The following codes* identify services that satisfy the measure:
Please click the icon below for allowable numerator codes:
Denominator
Women 52–74 years of age as of the end of the measurement
period.
Exclusions
Exclude women who had a bilateral mastectomy and for whom
administrative data doesn't indicate that a mammogram was
performed. Look for evidence of bilateral mastectomy as far back
as possible in the patient’s history, through either administrative
data or medical record review. The bilateral mastectomy must
have occurred by the end of the measurement period.
(Exclusionary evidence in the medical record must include a note
indicating a bilateral mastectomy.) If there is evidence of two
unilateral mastectomies, this patient may be excluded from the
measure. The unilateral mastectomies must have two separate
occurrences on two different dates that are 14 days or more apart
from each other. This measure will use the billing codes from
submitted claims to identify exclusions.
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
51
Cervical Cancer Screening
Supplemental Data Requirements
COMMERCIAL • QUEST INTEGRATION
To attest that a cervical cancer screening was performed,
medical record evidence of one of the following is required.
Description
• Cervical cytology
The percentage of women 24–64 years of age who were
screened for cervical cancer using either of the following criteria:
– A note indicating the date when the cervical cytology
was performed.
• Women ages 24–64 who had cervical cytology performed
every three years.
– The result or finding.
• Cervical cytology and HPV screening
• Women ages 30–64 who had cervical cytology and human
papillomavirus (HPV) co-testing performed every five years.
– A note indicating the date when the cervical cytology and the
HPV test were performed.
This measure follows the USPSTF guidelines for cervical cancer
screening (uspreventiveservicestaskforce.org/uspstf/
uspscerv.htm).
– The result or finding.
Note: Lab results that explicitly state that the sample was
inadequate or that “no cervical cells were present” isn’t
appropriate screening. Biopsies aren’t accepted because they’re
diagnostic and therapeutic only and aren’t valid for primary
cervical cancer screening.
Numerator
Patients who were screened for cervical cancer using either of
the following criteria:
• Patients 24–64 years of age who had cervical cytology during
the measurement year or the two years prior to the
measurement period.
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence of one of the following is required:
• Patients 30–64 years of age who had cervical cytology and a
human papillomavirus (HPV) test with service dates four or less
days apart during the measurement period or the four prior
measurement periods.
• Documentation of “complete,” “total,” or “radical” abdominal
or vaginal hysterectomy meets the criteria for hysterectomy
with no residual cervix.
The measure will use the billing codes from submitted claims to
identify cervical cancer screening.
• Documentation of “vaginal Pap smear” in conjunction with
documentation of “hysterectomy” meets the exclusion criteria,
but documentation of hysterectomy alone doesn’t meet
the criteria because it doesn’t indicate that the cervix
was removed.
Please click the icon below for allowable numerator codes:
Denominator
Measure Status
Women 24–64 years of age during the measurement period.
NQF # 0032
Original Endorsement Date: August 10, 2009
Status: Endorsed
Steward(s): NCQA
Exclusions
Evidence of a hysterectomy with no residual cervix at any time
in the patient’s history. The hysterectomy must have occurred by
the end of the measurement period.
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
52
Childhood Immunization Status
(All individual immunizations)
Supplemental Data Option Documentation
Requirements
COMMERCIAL • QUEST INTEGRATION
For MMR, hepatitis B, and VZV, medical record
evidence of one of the following is required:
Description
• Evidence of the antigen or combination vaccine.
Percentage of children 2 years of age who had four diphtheria,
tetanus, and acellular pertussis (DTaP); three polio (IPV);
one measles, mumps, and rubella (MMR); three Haemophilus
influenzae type b (Hib); two hepatitis B (HepB); one chicken pox
(VZV); and four pneumococcal conjugate (PCV) by their
second birthday.
• Documented history of the illness.
• A seropositive test for each antigen.
For DTaP, IPV, Hib, and pneumococcal conjugate, medical record
evidence of the following is required:
• Evidence of the antigen or combination vaccine.
This measure follows the Centers for Disease Control and
Prevention and the Advisory Committee on Immunization
Practices (ACIP) guidelines for immunizations. The measure
implements changes to the guidelines (e.g., new vaccine
recommendations) after three years to account for the measure’s
retrospective period and to allow the industry time to adapt to
new guidelines.
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence of the following is required:
For all antigens, count any of the following:
• Contraindications – a medical record note about contraindications specific to applicable immunizations that occurred before
the patient’s second birthday. Documentation should also
describe tests performed and the results.
• Evidence of the antigen or combination vaccine.
Measure Status
• Documented history of the illness.
NQF # 0038
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Numerator
• A seropositive test result.
This measure will use the billing codes from submitted claims
data to identify immunizations.
Please click the icon below for allowable numerator codes:
Denominator
Children who turn 2 years of age during the measurement period.
Exclusions
Children who had a contraindication for a specific vaccine will
be excluded. Exclude patients for contraindication only if the
administrative data don’t indicate that the contraindicated
immunization was rendered. The exclusion must have occurred
by the second birthday.
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
53
Chlamydia Screening for Women
Prescriptions to Identify Contraceptives
DESCRIPTION
COMMERCIAL • QUEST INTEGRATION
Contraceptives
Description
PRESCRIPTION
Desogestrel-ethinyl estradiol
Dienogest-estradiol multiphasic
Percentage of eligible women 16–24 years of age who were
identified as sexually active and had at least one test for
chlamydia during the measurement period. The chlamydia
screening measures follow the USPSTF guidelines
(uspreventiveservicestaskforce.org/Page/Topic/recommendationsummary/chlamydia-and-gonorrhea-screening).
Drospirenone-ethinyl estradiol
Drospirenone-ethinyl estradiol-levomefolatebiphasic
Estradiol-medroxyprogesterone
Ethinyl estradiol-ethynodiol
Numerator
Ethinyl estradiol-etonogestrel
Documentation in the medical record of at least one chlamydia
test during the measurement period. A woman is counted in the
numerator if there is documentation of a chlamydia trachomatis or species test with a service date during the measurement
period. This measure will use the billing codes from submitted
claims to identify chlamydia screening.
Ethinyl estradiol-levonorgestrel
Ethinyl estradiol-norelgestromin
Ethinyl estradiol-norethindrone
Ethinyl estradiol-norgestimate
Ethinyl estradiol-norgestrel
Please click the icon below for allowable numerator codes:
Etonogestrel
Levonorgestrel
Medroxyprogesterone
Denominator
Mestranol-norethindrone
Women 16–24 years of age as of the end of the measurement
period who are sexually active. Two methods are provided to
identify sexually active women: pharmacy data and claims/
encounter data. Both methods are used to identify the eligible
population, although a patient must appear in only one method to
be eligible for the measure.
Norethindrone
Diaphragm
Diaphragm
Spermicide
Nonxynol 9
Exclusions
Patients who were dispensed prescription contraceptives
(including diaphragm, spermicide) during the measurement
period qualify for this measure. (See prescriptions to identify
contraceptives table.)
Exclude patients who had a pregnancy test during the measurement period followed within seven days (inclusive) by either a
prescription for isotretinoin or an X-ray. This exclusion doesn’t
apply to patients who qualify for the denominator based on
services other than the pregnancy test alone.
Please click the icon below for allowable denominator codes:
Medications to Identify Exclusions
DESCRIPTION
Retinoid
PRESCRIPTION
isotretinoin
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
54
Supplemental Data Option Documentation
Requirements
Denominator
Patients 51–75 years of age during the measurement period.
To attest that a chlamydia screening was performed, medical
record evidence of the following is required:
Exclusions
Patients with a diagnosis of colorectal cancer or total colectomy.
Look for evidence of colorectal cancer or total colectomy as far
back as possible in the patient’s history through either administrative data or medical record review. Exclusionary evidence in
the medical record must include a note indicating a diagnosis of
colorectal cancer or total colectomy, which must have occurred
by the end of the measurement period.
• Chlamydia screening test – lab results or state note (free
chlamydia screening) indicating the date on which the test
was performed.
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence must indicate the patient had a pregnancy test during
the measurement period followed within seven days by one of
the following:
Please click the icon below for allowable exclusion codes:
• Isotretinoin prescription.
Supplemental Data Option Documentation
Requirements
• Radiology/X-ray note confirming that the service was
completed.
Measure Status
To attest that a colorectal cancer screening was performed,
medical record evidence of one of the following is required:
NQF # 0033
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
• FOBT – lab results/report for guaiac (gFOBT) or immunochemical (iFOBT). Depending on the type of FOBT test, the following
is the required number of samples:
Colorectal Cancer Screening
1. gFOBT – three consecutive stools
2. iFOBT – one stool
• Flex sigmoidoscopy – performed during the measurement
period or four years prior to the measurement period.
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
• Colonoscopy – performed during the measurement period or
nine years prior to the measurement period.
Description
Percentage of adults 51–75 years of age who had appropriate
screening for colorectal cancer. The colorectal cancer
screening measure follows the USPSTF guidelines
(uspreventiveservicestaskforce.org/uspstf/uspscolo.htm).
Note: A result isn’t required if the documentation is clearly part of
the “medical history” section of the record. However, if this isn’t
clear, the result or finding must also be present to ensure that
the screening was performed and not merely ordered. A digital
rectal exam doesn’t count as evidence of a colorectal screening
because it isn’t specific or comprehensive enough to screen for
colorectal cancer.
Numerator
Patients who had one or more screenings for colorectal cancer.
Appropriate screenings are defined by any one of the three
criteria below:
Documentation Requirements for Request
for Reconsideration
• Fecal occult blood test (FOBT) during the measurement period.
To attest that a patient should be excluded, medical record
evidence of one of the following is required:
• Flexible sigmoidoscopy during the measurement period or the
four prior measurement periods.
• Colorectal cancer.
• Colonoscopy during the measurement period or the nine prior
measurement periods.
• Total colectomy – including the date of the procedure.
Measure Status
This measure will use the billing codes from submitted claims to
identify colorectal cancer screening. The following codes* identify
services that satisfy the measure:
NQF # 0034
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Please click the icon below for allowable numerator codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
55
Comprehensive Diabetes Care
– Blood Pressure Control (<140/90)
Denominator
Patients 18–75 years of age at the end of the measurement
period who had a diagnosis of diabetes (type 1 or type 2) by a
provider qualified to make the diagnosis of diabetes for this
measure. Patients with diabetes can be identified during the
measurement period or the prior measurement period through:
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
Description
• Pharmacy data: Prescriptions that identify patients with
diabetes include insulin prescriptions (drug list available) and
oral hypoglycemics/antihyperglycemics prescriptions (drug list
available). Note: Glucophage/metformin isn’t included because
it’s used to treat conditions other than diabetes; patients with
diabetes on these medications are identified through diagnosis
codes only.
Percentage of patients with diabetes, 18–75 years of age, whose
blood pressure was adequately controlled (less than 140/90)
during the measurement period based on the most recent
blood pressure reading during the measurement period.
The comprehensive diabetes care – blood pressure controlled
measure is approved by NQF (qualityforum.org) and follows
American Diabetes Association guidelines (care.diabetesjournals.
org/content/33/Supplement_1/S11.full.pdf).
• A diagnosis of diabetes by a PCP as indicated on the problem
list or at least two visits with diabetes listed as a diagnosis.
Numerator
Please click the icon below for allowable denominator codes:
The number of patients in the denominator whose blood pressure
is adequately controlled during the measurement period. For a
patient’s blood pressure to be controlled, both the systolic and
diastolic blood pressure must be less than 140/90 (adequate
control). You must report the actual blood pressure reading to
satisfy measure reporting requirements.
Exclusions
To describe systolic and diastolic blood pressures, each must be
reported separately. If there are multiple blood pressures on the
same date of service, use the lowest systolic and lowest diastolic
blood pressure on that date as the representative blood pressure.
Exclude patients with a diagnosis of polycystic ovaries on the
problem list who didn’t also have a diagnosis of diabetes on the
problem list during the measurement period or the prior measurement period. Exclude patients with a diagnosis of gestational
diabetes or steroid-induced diabetes on the problem list during
the measurement period.
Your medical records must support the diagnosis for the
denominator and identify the actual blood pressure reading
for the numerator.
The patient must not have a face-to-face encounter in any setting
with a diagnosis of diabetes during the measurement period or
the year prior to the measurement period.
The following blood pressure readings don’t meet the criteria for
the numerator:
Please click the icon below for allowable exclusion codes:
• Blood pressure reading from an acute inpatient stay or an
emergency department visit.
Supplemental Data Option Documentation
Requirements
• Blood pressure reading from an outpatient visit, the sole
purpose of which was to have a diagnostic test or surgical
procedure performed.
To attest that the patient’s blood pressure is controlled, medical
record evidence of the following is required:
• Blood pressure reading done on the same day as a major
diagnostic or surgical procedure.
• Blood pressure test – medical note that indicates the date the
blood pressure test was performed and the systolic and
diastolic values that were collected.
• Blood pressure reading reported or taken by the patient.
If there are no blood pressure readings that meet the criteria after
the diagnosis of hypertension, the patient can’t be included in the
numerator.
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence of the following is required:
Please click the icon below for allowable numerator codes:
The patient must not have a face-to-face encounter in any
setting with a diagnosis of diabetes during the measurement
period or the prior measurement period and have one of the
following diagnoses:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
56
• Polycystic ovaries – note indicating a diagnosis of polycystic
ovaries, in any setting, any time in the patient's history prior to
the end of the measurement period.
Denominator
Patients 18–75 years of age at the end of the measurement
period who had a diagnosis of diabetes (type 1 or type 2) by a
provider qualified to make the diagnosis of diabetes for this
measure. Patients with diabetes can be identified during the
measurement period or the prior measurement period through:
• Gestational or steroid-induced diabetes – note indicating a
diagnosis of gestational or steroid-induced diabetes, in any
setting, during the measurement period or the prior measurement period.
• Pharmacy data: Patients who were prescribed insulin or oral
hypoglycemics/antihyperglycemics on an ambulatory basis.
Prescriptions to identify patients with diabetes include insulin
prescriptions (drug list is available) and oral hypoglycemics/
antihyperglycemics prescriptions (drug list is available).
Measure Status
NQF # 0061
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Note: Glucophage/metformin isn’t included because it’s used
to treat conditions other than diabetes; members with
diabetes on these medications are identified through
diagnosis codes only.
Comprehensive Diabetes Care
– Eye Exam
• A diagnosis of diabetes by a primary care physician as
indicated on the problem list or at least two visits with
diabetes listed as a diagnosis.
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
Please click the icon below for allowable denominator codes:
Description
Percentage of diabetes patients 18–75 years of age who
received a dilated eye exam, seven standard field stereoscopic
photos with interpretation by an ophthalmologist or optometrist,
or imaging validated to match diagnosis from these photos
during the measurement period. A negative dilated eye exam
(negative for retinopathy) in the prior measurement period also
meets criteria for the eye exam indicator.
Exclusions
Blindness isn’t an exclusion for a diabetic eye exam because it's
difficult to distinguish between individuals who are legally blind
but require a retinal exam and those who are completely blind
and therefore don’t require an exam.
The eye exam measure is approved by the National Quality
Forum (qualityforum.org/) and follows American Diabetes
Association guidelines (care.diabetesjournals.org/content/33/
Supplement_1/S11.full.pdf).
Exclude patients with a diagnosis of polycystic ovaries on the
problem list who didn’t also have a diagnosis of diabetes on the
problem list during the measurement period or prior measurement period. Exclude patients with a diagnosis of gestational
diabetes or steroid-induced diabetes on the problem list during
the measurement period. The patient must not have a face-toface encounter in any setting with a diagnosis of diabetes
during the measurement period or the year prior to the
measurement period.
Numerator
This measure will use the billing codes from submitted claims to
identify eye exams. The following codes* identify services that
satisfy the measure.
Please click the icon below for allowable numerator codes:
Please click the icon below for allowable exclusion codes:
Eye exams provided by eye care professionals are a proxy for
dilated eye examinations because there is no administrative way
to determine that a dilated exam was performed.
Supplemental Data Option Documentation
Requirements
To attest that an eye exam screening was performed, medical
record evidence of one of the following is required:
• Dilated eye exam – documentation of a retinal or dilated eye
exam by an optometrist or ophthalmologist during the measurement period.
• Negative retinal eye exam – documentation of a negative eye
exam (no evidence of retinopathy) from an ophthalmologist/
optometrist in the year prior to the measurement period.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
57
Documentation Requirements for Request
for Reconsideration
Denominator
Patients 18–75 years of age as of the end of the measurement
period who had a diagnosis of diabetes (type 1 or type 2) by a
provider qualified to make the diagnosis of diabetes for this
measure. Patients with diabetes can be identified during the
measurement period or the prior measurement period through
pharmacy data or diagnosis.
To attest that a patient should be excluded, medical record
evidence of the following is required:
The patient must not have a face-to-face encounter in any
setting with a diagnosis of diabetes during the measurement
period or the prior measurement period and have one of the
following diagnoses:
• P
harmacy data: Prescriptions that identify patients with diabetes
include insulin prescriptions (drug list available) and oral hypoglyemics/antihyperglycemics prescriptions (drug list available).
Note: Glucophage/metformin isn’t included because it’s used to
treat conditions other than diabetes; patients with diabetes on
these medications are identified through diagnosis codes only.
• Polycystic ovaries – note indicating a diagnosis of polycystic
ovaries, in any setting, any time in the patient’s history prior to
the end of the measurement period.
• Gestational or steroid-induced diabetes – note indicating a
diagnosis of gestational or steroid-induced diabetes, in any
setting, during the measurement period or the prior
measurement period.
• Diagnosis: A diagnosis of diabetes on the problem list or at
least two visits with diabetes listed as a diagnosis.
Please click the icon below for allowable denominator codes:
Measure Status
NQF # 0055
Status: Endorsed
Original Endorsement Date: August10, 2009
Steward(s): NCQA
Exclusions
Exclude patients with a diagnosis of polycystic ovaries on
the problem list who didn’t also have a diagnosis of diabetes
on the problem list during the measurement period or the prior
measurement period. Exclude patients with a diagnosis of
gestational diabetes or steroid-induced diabetes on the problem
list during the measurement period.
Comprehensive Diabetes Care –
HbA1c Control (<8.0%)
QUEST INTEGRATION
Excluded patients must not have a face-to-face encounter in
any setting with a diagnosis of diabetes during the measurement
period or the year prior to the measurement period.
Description
Percentage of patients with diabetes, 18–75 years of age, whose
most recent HbA1c level was less than 8.0 percent (in control).
Please click the icon below for allowable exclusion codes:
The comprehensive diabetes care – blood sugar controlled measure is approved by NQF (qualityforum.org) and follows American
Diabetes Association guidelines (care.diabetes journals.org/
content/33/Supplement_1/S11.full.pdf).
Supplemental Data Option Documentation
Requirements
Numerator
This measure will use the most recent HbA1c test performed
during the measurement period with a result of less than 8.0
percent. If the result for the most recent HbA1c test is greater than
8.0 percent, missing, or wasn’t performed during the measurement
period, the patient won’t be included in the numerator.
To attest that the patient’s blood sugar is controlled, medical
record evidence of the following is required:
Actual lab values for the most recent HbA1c test must be
provided to satisfy measure reporting requirements.
Documentation Requirements for Request
for Reconsideration
Please click the icon below for allowable numerator codes:
To attest that a member should be excluded, medical record
evidence of the following is required:
• HbA1c Test – a lab report, medical note, or in-house
lab printout that indicates the date the HbA1c test was
performed and the value that was collected.
The patient must not have a face-to-face encounter in any setting
with a diagnosis of diabetes during the measurement period or the
prior measurement period and have one of the following diagnoses:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
**Code isn't limited to optometrist or ophthalmologist.
58
• Pharmacy data: Patients who were prescribed insulin or oral
hypoglycemics/antihyperglycemics on an ambulatory basis.
Prescriptions to identify patients with diabetes include insulin
prescriptions (drug list is available) and oral hypoglycemics/
antihyperglycemics prescriptions (drug list is available). Note:
Glucophage/metformin isn’t included because it’s used to treat
conditions other than diabetes; members with diabetes on
these medications are identified through diagnosis codes only.
Polycystic ovaries – note indicating a diagnosis of polycystic
ovaries, in any setting, any time in the patient’s history prior to the
end of the measurement period.
• Gestational or steroid-induced diabetes – note indicating a
diagnosis of gestational or steroid-induced diabetes, in any
setting, during the measurement period or the prior
measurement period.
• A diagnosis of diabetes by a PCP as indicated on the problem
list or at least two visits with diabetes listed as a diagnosis.
Measure Status
NQF # 0059
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Please click the icon below for allowable denominator codes:
Exclusions
Comprehensive Diabetes Care
– HbA1c in Control (≤9)
Exclude patients with a diagnosis of polycystic ovaries on the
problem list who didn’t also have a diagnosis of diabetes on the
problem list during the measurement period or the prior measurement period. Exclude patients with a diagnosis of gestational
diabetes or steroid-induced diabetes on the problem list during
the measurement period or prior measurement period.
The patient must not have a face-to-face encounter in any
setting with a diagnosis of diabetes during the measurement
period or the year prior to the measurement period.
COMMERCIAL • HMSA AKAMAI ADVANTAGE
Description
The percentage of patients with diabetes 18–75 years of age
whose most recent HbA1c level during the measurement period
was less than or equal to 9.0 percent (in control).
The comprehensive diabetes care – HbA1c in control measure is
approved by NQF (qualityforum.org) and follows American
Diabetes Association guidelines (care.diabetesjournals.org/
content/33/Supplement_1/S11.full.pdf).
Please click the icon below for allowable exclusion codes:
Numerator
Supplemental Data Option Documentation
Requirements
The number of patients whose most recent HbA1c test
performed during the measurement period had a result less than
or equal to 9.0 percent, was missing a result, or the last test was
not performed during the measurement period. If the result for the
most recent HbA1c test during the measurement period is greater
than 9.0 percent, the patient won't be included in the numerator.
To attest that the patient’s HbA1c is in control, medical record
evidence of the following is required:
• HbA1c test – a lab report, medical note, or in-house lab
printout that indicates the date the HbA1c test was performed
and the value that was collected.
Actual lab values for the most recent HbA1c test must be
provided to satisfy measure reporting requirements.
Documentation Requirements for Request
for Reconsideration
Please click the icon below for allowable numerator codes:
To attest that a patient should be excluded, medical record
evidence of the following is required:
The patient must not have a face-to-face encounter in any
setting with a diagnosis of diabetes during the measurement
period or the prior measurement period and have one of the
following diagnoses:
Denominator
Patients 18–75 years of age at the end of the measurement
period who had a diagnosis of diabetes (type 1 or type 2) by a
provider qualified to make the diagnosis of diabetes for this
measure. Patients with diabetes can be identified during the
measurement period or the prior measurement period through:
Polycystic ovaries – note indicating a diagnosis of polycystic
ovaries, in any setting, any time in the patient’s history prior to the
end of the measurement period.
• Gestational or steroid-induced diabetes – note indicating a
diagnosis of gestational or steroid-induced diabetes, in any
setting, during the measurement period or the prior
measurement period.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
59
• A diagnosis of diabetes by a PCP as indicated on the problem
list or at least two visits with diabetes listed as a diagnosis.
Measure Status
NQF # 0059
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
Please click the icon below for allowable denominator codes:
Exclusions
Comprehensive Diabetes Care
– Medical Attention for
Nephropathy
Exclude patients with a diagnosis of polycystic ovaries on the
problem list who didn’t also have a diagnosis of diabetes on the
problem list during the measurement period or the prior
measurement period. Exclude patients with a diagnosis of
gestational diabetes or steroid-induced diabetes on the problem
list during the measurement period. The patient must not have a
face-to-face encounter in any setting with a diagnosis of diabetes
during the measurement period or the year prior to the
measurement period.
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
Description
Percentage of diabetes patients 18–75 years of age with at
least one test for microalbumin during the measurement period
or evidence of medical attention for existing nephropathy
(diagnosis of nephropathy or documentation of microalbuminuria
or albuminuria).
Please click the icon below for allowable exclusion codes:
This measure is approved by the National Quality Forum
(qualityforum.org/) and follows American Diabetic
Association guidelines (care.diabetesjournals.org/content/33/
Supplement_1/S11.full.pdf).
Supplemental Data Option Documentation
Requirements
To attest that the patient has a diagnosis of nephropathy, medical
record evidence of one of the following is required:
Numerator
• Diabetic nephropathy screening test – lab report or medical
record note indicating the date when a urine microalbumin test
was performed and the results.
Patients who had any one of the following:
• Screening for nephropathy.
• Evidence of nephropathy – documentation of a visit to a
nephrologist, renal transplantation, or medical attention for
diabetic nephropathy, ESRD, CRF, CKD, renal insufficiency,
proteinuria, albuminuria, renal dysfunction, acute renal failure
(ARF), or dialysis.
• Evidence of nephropathy.
• Evidence of ACE inhibitor/ARB therapy.
This measure will use pharmacy claims data to identify evidence
of ACE inhibitor or ARB therapy. This measure will also use the
billing codes from submitted claims to identify screening for
nephropathy and evidence of nephropathy.
Please click the icon below for allowable numerator codes:
• Positive urine macroalbumin test – lab report or medical record
note indicating the date when the macroalbumin
test was performed and a positive result. Trace urine
macroalbumin test results aren’t considered valid
documentation for this measure.
Denominator
• Evidence of ACE inhibitor/ARB medication therapy –
at minimum, a note indicating that the member received an
ambulatory prescription for ACE inhibitors/ARBs in the
measurement period.
Patients 18–75 years of age at the end of the measurement
period who had a diagnosis of diabetes (type 1 or type 2) by a
provider qualified to make the diagnosis of diabetes for this
measure. Patients with diabetes can be identified during the
measurement period or the prior measurement period through:
Documentation Requirements for Request
for Reconsideration
To attest that a patient should be excluded, medical record
evidence of the following is required:
• Pharmacy data: Patients who were prescribed insulin or oral
hypoglycemics/antihyperglycemics on an ambulatory basis.
Prescriptions to identify patients with diabetes include insulin
prescriptions (drug list is available) and oral hypoglycemics/
antihyperglycemics prescriptions (drug list is available).
Note: Glucophage/metformin isn’t included because it’s used
to treat conditions other than diabetes; patients with
diabetes on these medications are identified through
diagnosis codes only.
The patient must not have a face-to-face encounter in any setting
with a diagnosis of diabetes during the measurement period or
the prior measurement period and have one of the following
diagnoses:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
60
• Polycystic ovaries – note indicating a diagnosis of
polycystic ovaries, in any setting, any time in the patient’s
history prior to the end of the measurement period.
The following blood pressure readings don’t meet the criteria for
the numerator:
• Blood pressure reading from an acute inpatient stay or an
emergency department visit.
• Gestational or steroid-induced diabetes – note indicating a
diagnosis of gestational or steroid-induced diabetes, in any
setting, during the measurement period or the prior
measurement period.
• Blood pressure reading from an outpatient visit, the sole
purpose of which was to have a diagnostic test or surgical
procedure performed.
Measure Status
• Blood pressure reading done on the same day as a major
diagnostic or surgical procedure.
NQF # 0062
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
• Blood pressure reading reported or taken by the patient.
If there are no blood pressure readings that meet the criteria after
the diagnosis of hypertension, the patient can’t be included in the
numerator.
Controlling Blood Pressure
For patients with Medicare primary coverage and HMSA
Commercial secondary coverage:
COMMERCIAL • QUEST INTEGRATION • HMSA AKAMAI
ADVANTAGE
Medicare does not recognize these CPT II codes, and claims
forwarded by Medicare to HMSA won't result in numerator credit
for the blood pressure measure.
Description
The percentage of members 18–85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled
during the measurement year based on the following criteria:
To get numerator credit, report compliant blood pressures
through Supplemental Data on Cozeva or submit a secondary
claim with the blood pressure codes to HMSA.
• Patients 18–59 years of age whose BP was <140/90 mm Hg.
Note: There are no procedure codes to describe a systolic
pressure of 140 to 149 mm Hg. Therefore, controlled blood
pressure for a patient between 60 to 85 years of age (i.e., one
with a systolic pressure of 140 to 149 mm Hg and a diastolic
pressure of <90 mm Hg) must be reported using Cozeva
supplemental data.
• Patients 60–85 years of age with a diagnosis of diabetes
whose BP was <140/90 mm Hg.
• Patients 60–85 years of age without a diagnosis of diabetes
whose BP was <150/90 mm Hg.
Numerator
Denominator
The number of patients in the denominator whose most recent
blood pressure is adequately controlled during the measurement
period as reported from a visit where hypertension was addressed.
Patients 18–85 years of age who had a diagnosis of hypertension. Patients are considered hypertensive if they have at least
one outpatient encounter with a diagnosis of hypertension
during an 18-month window (the 12 months prior to the start of
the measurement period and the first six months of the measurement period).
Please click the icon below for allowable numerator codes:
Please click the icon below for allowable denominator codes:
You must report the actual blood pressure reading to satisfy
measure reporting requirements. To describe systolic and diastolic blood pressures, each must be reported separately. If there
are multiple blood pressures on the same date of service, use the
lowest systolic and lowest diastolic blood pressure on that date
as the representative blood pressure.
Exclusions
Your medical records must support the diagnosis for the
denominator and identify the representative blood pressure
reading for the numerator.
Please click the icon below for allowable exclusion codes:
Exclude all patients who have evidence of ESRD (including
dialysis or renal transplant), are pregnant, or who had a
non-acute inpatient encounter during the measurement period.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
61
Supplemental Data Option Documentation
Requirements
Denominator
Adolescents who turn 13 years of age during the
measurement period.
To attest that the patient’s blood pressure is controlled,
medical record evidence of the following is required:
Exclusions
• Blood pressure test – medical note that indicates the date the
blood pressure test was performed and the systolic and
diastolic values that were collected.
Adolescents who have a contraindication for one of these
vaccines. Exclusion must have occurred before the adolescent's
13th birthday.
Documentation Requirements for Request
for Reconsideration
Please click the icon below for allowable exclusion codes:
To attest that a patient should be excluded, medical record
evidence of one of the following is required:
Supplemental Data Option Documentation
Requirements
• A note indicating a diagnosis of ESRD during the
measurement period. Documentation of dialysis or renal
transplant also meets the criteria for evidence of ESRD.
To attest that a patient received the proper vaccinations, medical
record evidence must include the following:
• A note indicating a diagnosis of pregnancy during the
measurement period.
• A note indicating a non-acute inpatient encounter during the
measurement year.
• A medical record documentation showing evidence of the
antigen or combination vaccine for meningococcal vaccine and
Tdap or Td.
Measure Status
Measure Status
NQF # 0018
Status: Endorsed
Original Endorsement Date: August 10, 2009
Steward(s): NCQA
NQF # 1407
Status: Endorsed
Original Endorsement Date: August 15, 2011
Steward(s): NCQA
Immunizations for Adolescents
(All individual immunizations)
COMMERCIAL • QUEST INTEGRATION
Description
The percentage of adolescents 13 years of age who had one
dose of meningococcal vaccine and one tetanus, diphtheria, and
acellular pertussis vaccine (Tdap) or one tetanus and diphtheria
toxoids vaccine (Td) by their 13th birthday. The measure
calculates a rate for each vaccine and one combination rate.
Numerator
Adolescents who receive both:
• One meningococcal conjugate or meningococcal
polysaccharide vaccine on or between their 7th and
13th birthdays.
• One Tdap or one Td on or between their 10th and
13th birthdays.
Please click the icon below for allowable numerator codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
62
Medication Adherence for
Cholesterol (Statins)
Denominator
Number of patients with at least two fills of either the same statin
medication or medications in the same drug class during the
measurement period.
HMSA AKAMAI ADVANTAGE
Supplemental Data Option Documentation
Requirements
Description
The percentage of patients (18 years of age or older) who
adhered to their prescribed drug therapy for statin
cholesterol medications.
Supplemental data won’t be accepted for this measure.
Measure Status
Numerator
NQF # 0541
Status: Endorsed
Original Endorsement Date: August 5, 2009
Steward(s): Pharmacy Quality Alliance
Number of patients with a proportion of days covered of 80
percent or over for statin cholesterol medications during the
measurement period. A patient with a proportion of days covered
threshold of at least 80 percent is considered to be adherent. The
steps used to calculate the numerator are below.
Step 1:Determine the patient’s measurement period in days,
starting at the date of the first fill and ending at the end
of the measurement period, disenrollment, or death.
Step 2:Within the measurement period, count the number of
days the patient was “covered” by at least one drug in
the therapeutic area based on the prescription fill date
and days of supply. If prescriptions for the same drug
(same generic code number) overlap, adjust the
prescription start date to be the day after the previous
fill ends.
Step 3: Divide the number of days found in Step 2 by the
number of days found in Step 1 to determine the
proportion of days covered.
Step 4: Count the number of patients whose proportion of days
covered was greater than or equal to 0.80.
Statin cholesterol medications
• atorvastatin
• fluvastatin
• lovastatin
• pitavastatin
• pravastatin
• rosuvastatin
• simvastatin
Statin combination products
• atorvastatin & amlodipine
• ezetimibe & atorvastatin
• ezetimibe & simvastatin
• niacin & lovastatin
• niacin & simvastatin
• sitagliptin & simvastatin
Note: Active ingredients are limited to oral formulations only
(includes all dosage forms).
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
63
Medication Adherence for
Hypertension (RAS Antagonist)
• quinapril & HCTZ
• trandolopril-verapamil HCL
ARB combination products
HMSA AKAMAI ADVANTAGE
• aliskiren & valsartan
Description
• amlodipine & olmesartan
The percentage of patients (18 years of age or older) who
adhered to their prescribed drug therapy for RAS antagonists.
• amlodipine & valsartan
• amlodipine & valsartan & HCTZ
Numerator
• azilsartan & chlorthalidone
Number of patients with a proportion of days covered of
80 percent or over for RAS antagonist medications during the
measurement period. A patient with a proportion of days covered
threshold of at least 80 percent is considered to be adherent.
The steps used to calculate the numerator are below.
• candesartan & HCTZ
Step 1: Determine the patient’s measurement period in days,
starting at the date of the first fill and ending at the end
of the measurement period, disenrollment, or death.
• olmesartan & amlodipine & HCTZ
• eprosartan & HCTZ
• irbesartan & HCTZ
• losartan & HCTZ
• olmesartan & HCTZ
• telmisartan & amlodipine
Step 2: Within the measurement period, count the number of
days the patient was “covered” by at least one drug in
the therapeutic area based on the prescription fill date
and days of supply. If prescriptions for the same drug
(same generic code number) overlap, adjust the
prescription start date to be the day after the previous
fill ends.
• telmisartan & HCTZ
• valsartan & HCTZ
ARB hypertension medications
• azilsartan
• candesartan
Step 3: Divide the number of days found in Step 2 by the
number of days found in Step 1 to determine the
proportion of days covered.
• eprosartan
• irbesartan
• losartan
Step 4:Count the number of patients whose proportion of days
covered was greater than or equal to 0.80.
• olmesartan
• telmisartan
ACEI medications
• valsartan
• benazepril
Direct renin inhibitor medications
• captopril
• aliskiren
• enalapril
Direct renin inhibitor combination products
• fosinopril
• lisinopril
• aliskiren & amlodipne
• moexipril
• aliskiren & amlodipine & HCTZ
• perindopril
• aliskiren & HCTZ
• quinapril
• aliskiren & valsartan
• ramipril
Note: Active ingredients are limited to oral formulations only.
Excludes nutritional supplement/dietary management
combination products.
• trandolopril
ACEI combination products
• amlodipine & benazepril
• benazepril & HCTZ
• captopril & HCTZ
• enalapril & HCTZ
• fosinopril & HCTZ
• lisinopril & HCTZ
• moexipril & HCTZ
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
64
Denominator
Oral diabetes medications:
Number of patients with at least two fills of either the same
medication or medications in the same drug class during the
measurement period.
Biguanide medications
• alogliptin & metformin
• glipizide & metformin
COMMERCIAL
• glyburide & metformin
Scoring will exclude members who don't have an HMSA drug
plan and will only include those members with both HMSA
medical and drug plans.
• linagliptin & metformin
Supplemental Data Option Documentation
Requirements
• pioglitazone & metformin
Supplemental data won’t be accepted for this measure.
• rosiglitazone & metformin
• metformin
• repaglinide & metformin
• saxagliptin & metformin SR
Measure Status
• sitagliptin & metformin IR & SR
NQF # 0541
Status: Endorsed
Original Endorsement Date: August 5, 2009
Steward(s): Pharmacy Quality Alliance
Note: Active ingredients are limited to oral formulations only
(includes all dosage forms). Excludes nutritional supplement/
dietary management combination products.
DPP-IV inhibitor medications
Medication Adherence for
Oral Diabetes Medications
• alogliptin
• alogliptin & metformin
• alogliptin & pioglitazone
HMSA AKAMAI ADVANTAGE
• linagliptin
Description
• linagliptin & metformin
The percentage of patients (18 years of age or older) who
adhered to their prescribed drug therapy across the following
classes of oral diabetes medications: biguanides, sulfonylureas,
thiazolidinediones, and DPP-IV inhibitors.
• saxagliptin
Numerator
• sitagliptin & metformin IR & SR
• saxagliptin & metformin SR
• sitagliptin
• sitagliptin & simvastatin
Number of patients with a proportion of days covered of
80 percent or more across the classes of oral diabetes medications during the measurement period. A patient with a proportion
of days covered threshold of at least 80 percent is considered to
be adherent. The steps used to calculate the numerator
are below.
Incretin mimetic agents
• exenatide
• liraglutide
Meglitinides
Step 1:Determine the patient’s measurement period in days,
starting at the date of the first fill and ending at the end
of the measurement period, disenrollment, or death.
• nateglinide
• repaglinide
• repaglinide & metformin
Step 2:Within the measurement period, count the number of
days the patient was “covered” by at least one drug in
the therapeutic area based on the prescription fill date
and days of supply. If prescriptions for the same drug
(same generic code number) overlap, adjust the
prescription start date to be the day after the previous
fill ends.
Sulfonylurea medications
• chlorpropamide
• glimepiride
• glipizide
• glipizide & metformin
Step 3:Divide the number of days found in Step 2 by the
number of days found in Step 1 to determine the
proportion of days covered.
• glyburide
• glyburide & metformin
• pioglitazone & glimepiride
Step 4:Count the number of patients who had a proportion of
days covered greater than or equal to 0.80.
• rosiglitazone & glimepiride
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
65
Medication Management for
People with Asthma
• tolazamide
• tolbutamide
Note: Active ingredients are limited to oral formulations only
(includes all salts and dosage forms).
COMMERCIAL • QUEST INTEGRATION
Description
Thiazolidinedione medications
• pioglitazone & glimepiride
The percentage of patients 5–85 years of age during the
measurement year who were identified as having persistent
asthma, filled prescriptions for appropriate medications, and
adhered to their medication during the treatment period.
• pioglitazone & metformin
Numerator
• alogliptin & pioglitazone
• pioglitazone
• rosiglitazone
Medication compliance 75 percent – The number of patients
who achieved PDC of at least 75 percent for their controller
medications during the measurement year. (See Asthma Controller and Reliever Medication table on page 67.)
• rosiglitazone & glimepiride
• rosiglitazone & metformin
Note: The active ingredients are limited to oral, inhaled, and
injectable formulations only (includes all dosage forms).
Excludes nutritional supplement/dietary management
combination products.
Steps to Identify Numerator Compliance:
1.Identify the index prescription start date (IPSD), which is the
earliest dispensing event for any asthma controller medication
during the measurement year.
Denominator
2.To determine the treatment period, calculate the number
of days from the IPSD (inclusive) to the end of the
measurement year.
Number of patients with at least two fills of medication(s) in any
of the drug classes during the measurement period.
Exclusions
3.Count the days covered by at least one prescription for an
asthma controller medication during the treatment period.
Subtract any days supply that extends beyond December 31
of the measurement year; days after the measurement year
shouldn’t be counted.
Exclude patients who were prescribed one or more prescriptions
for insulin during the measurement period.
Supplemental Data Option Documentation
Requirements
4.Calculate the patient’s PDC using the following equation
(round [using the 0.5 rule] to two decimal places):
Supplemental data won’t be accepted for this measure.
Measure Status
Total Days Covered by a
Controller Medication in the Treatment Period
NQF # 0541
Status: Endorsed
Original Endorsement Date: August 5, 2009
Steward(s): Pharmacy Quality Alliance
Total Days in Treatment Period
Denominator
All patients 5–85 years of age by the end of the measurement
year who were identified as having persistent asthma.
Patients are identified as having persistent asthma when they
have one or more of the following during both the measurement
year and the year prior:
• At least one emergency department visit or acute inpatient visit
with asthma as the principal diagnosis.
• At least four outpatient asthma visits on different dates of
service and at least two asthma medications.
• At least four asthma medication dispensing events.
Please click the icon below for allowable denominator codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
**Use ICD-9-CM Diagnosis code 999.4 (without fifth digit) to identify anaphylactic reaction prior to October 1, 2011.
66
Asthma Controller and Reliever Medications
ASTHMA CONTROLLER MEDICATIONS
DESCRIPTION
PRESCRIPTIONS
Antiasthmatic combinations
Dyphylline-guaifenesin
Antibody inhibitors
Omalizumab
Guaifenesin-theophylline
Inhaled steroid combinations
Budesonide-formoterol
Fluticasone-salmeterol
Mometasone-formoterol
Inhaled corticosteroids
Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone CFC free
Mometasone
Leukotriene modifiers
Montelukast
Zafirlukast
Zileuton
Mast cell stabilizers
Cromolyn
Methylxanthines
Aminophylline
Dyphylline
Theophylline
ASTHMA RELIEVER MEDICATIONS
DESCRIPTION
Short-acting, inhaled
beta-2 agonists
PRESCRIPTIONS
Albuterol
Levalbuterol
Pirbuterol
Exclusions
Exclude patients who had any diagnosis below any time during
the patient’s history through the end of the measurement year.
Please click the icon below for allowable exclusion codes:
Supplemental Data Option Documentation
Requirements
Supplemental data won't be accepted for this measure.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
67
Review of Chronic Conditions
Claims processing logic will also give providers credit for coding
conditions of greater severity to a higher level of specificity. When
a more severe diagnosis is reported, any gap(s) on a condition of
lesser severity will automatically be closed.
HMSA AKAMAI ADVANTAGE
2016 Modifications
Denominator
• The Review of Chronic Conditions (RCC) measure will be
subject to a measurement period of January 1, 2016, to
September 30, 2016, with supplemental data due by
September 30, 2016, and a one-month claims run-out.
The cumulative number of persistent conditions for all HMSA
Akamai Advantage members in the PCP’s patient panel identified
during the 24 months prior to the start of the measurement
period. Persistent conditions are identified through diagnosis
codes in medical claims from the PCP and/or from the specialty
and facility types on the inclusion lists in Tables 2a and 2b, only
when these codes have been recoded in the measurement
period. These lists exclude specialty and facility types that would
submit medical claims that aren’t used for RAPS/EDPS
submissions (e .g., lab, durable medical equipment, and a subset
of specialists). In addition, supplemental data will be used
(e .g., electronic medical record, retrospective chart audit RAPS/
EDPS return files, patient assessment form RAPS/EDPS return
files) when available. Suspect conditions identified by CCS will
not be included in the denominator.
• Measure will be displayed in the Cozeva Coding Specificity
(CCS) tool. CCS analytics identifies acute as well as chronic
conditions that may not have been coded in the past or may
not have been coded specifically. It identifies suspect conditions by taking into account all of the data available to Cozeva,
including:
– Prescriptions indicative of certain acute conditions.
– Abnormal lab results and frequency of certain lab tests.
– Frequency of visits to specialists.
– Hospital stays and/or ER visits.
Refer to the crosswalk in Cozeva to view which codes fall into
each diagnosis group (HCC).
–P
otential progression of certain chronic conditions from
previous years.
To help inform you why a patient qualifies for a particular
persistent condition, Cozeva will display all medical claims that
support the condition and the details of each supporting medical
claim, including:
– Coding habits of providers as evident in the practice patterns.
Description
HMSA Akamai Advantage patients often have conditions that
persist from year to year. The review of chronic conditions
measure encourages you to review each of your patients’
persistent conditions and care plans. The measure groups all
patient diagnoses identified over two calendar years prior to the
measurement period into clinically meaningful condition
groupings or codes called Hierarchical Condition Categories
(HCC). You must review and confirm the persistence of each
clinical condition group or code every calendar year. HMSA will
audit provider reviews because they will be used for Risk
Adjustment Processing System (RAPS) and Encounter Data
Processing System (EDPS) submissions.1 See Table 1 for a list of
the persistent conditions included in this measure.
• Name of the diagnosing provider.
• Diagnosis.
• Reimbursement specialty description of the
diagnosing provider.
• Service date.
Exclusions
In the final performance scoring, all numerator negative conditions that were exclusively coded by ED physicians, the hospital,
and hospitalists during the two year look-back period for the
measure will be removed. If these exclusions eliminate all chronic
conditions of any given member, that member won’t contribute to
the PCP’s scoring or max potential for the measure.
The RCC measure will be scored on the chronic conditions coded
in the previous two years by a patient’s attributed PCP and
treating specialist(s).
New manifestations or complications of persistent conditions for
medical claims received in 2015 won’t be included in the denominator for this measure.
Numerator
The cumulative number of persistent conditions that were
confirmed by medical claims (from both providers and facilities)
submitted with dates of service within the measurement period.
Suspect conditions identified by CCS that were confirmed by
medical claims submitted with dates of service within the measurement period will also be awarded numerator credit.
To receive credit for the confirmation, you must have a
face-to-face visit with your patient during the measurement
period. If an audit finds that you didn’t have a face-to-face visit
with your patient, the patient won’t be counted toward your
maximum payment potential and all confirmed conditions for the
patient will be removed from the numerator and denominator.
CMS instituted a Risk Adjustment Payment Model in 2004 to align payment to health plans with the disease burden and associated potential cost of the
plan’s beneficiaries. Data collected from this measure will be used to supplement our risk adjusted score through RAPS/EDPS submissions to CMS.
1
68
Supplemental Data
Primary care providers may request that the persistent condition
be excluded from the measure for one of the following rationales:
• Disconfirm – Condition has improved (e.g., the patient has
been diagnosed with a condition of lesser severity)
–A
n upload of the patient’s pertinent medical record
is required.
–D
ocumentation must include a face-to-face visit in the
calendar year (service date) that clearly demonstrates that the
patient’s condition has been managed/monitored, evaluated,
assessed, or treated and that the patient’s symptoms, labs,
medication, and treatment are consistent with a condition of
lesser severity (diagnosis and diagnosis code) than what is
currently reported on Cozeva.
• Disconfirm – Condition has resolved (e.g., the patient’s care
is no longer affected by the condition)
–A
n upload of the patient’s pertinent medical record
is required.
–D
ocumentation must include a face-to-face visit in the
calendar year (service date) that clearly demonstrates that the
patient’s symptoms, labs, and other diagnostic work indicate
that the condition no longer needs to be managed/monitored,
evaluated, assessed, or treated.
• Disconfirm – Insufficient evidence of the condition
–M
edical record documentation is not required for this
rationale/option. Instead, an attestation (e.g., note or
memo uploaded into Cozeva or text entered into Cozeva)
is required.
–T
he attestation must demonstrate that the provider reviewed
the pertinent clinical information (such as medical record
notes, consult reports, lab results, or imaging over the past
two years) and on the basis of those results, finds:
• Insufficient evidence to support the diagnosis; OR
• Clinical information to the contrary of the diagnosis.
–T
he attestation should be specific to the patient and
condition, and provide clinical rationale to the extent
possible. Example attestation: “I, Dr. Aloha Lee, do hereby
attest that this patient does not have the diagnosis of chronic
renal disease. The patient has had normal creatinine levels
seen over the past two years. Based on this history and my
physical examination, this patient does not have the
diagnosis of chronic renal disease.”
All supplemental data are subject to audit. All disconfirm submissions that pass audit will result in the removal of the condition
from the denominator, which will be reflected in your Cozeva
registry automatically.
All supplemental data for the Review of Chronic Conditions
measure must be submitted by September 30, 2015.
69
Table 1: Persistent Conditions
1
Amputation Status, Lower Limb/Amputation Complications
42
Pneumococcal Pneumonia, Emphysema, Lung Abscess
2
Angina Pectoris/Old Myocardial Infarction
43
Polyneuropathy
3
Artificial Openings for Feeding or Elimination
44
Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
4
Aspiration and Specified Bacterial Pneumonias
45
Protein-Calorie Malnutrition
5
Bone/Joint/Muscle Infections/Necrosis
46
Quadriplegia, Other Extensive Paralysis
6
Breast, Prostate, Colorectal, and Other Cancers and Tumors
47
Renal Failure
7
Cardio-Respiratory Failure and Shock
48
Respirator Dependence/Tracheostomy Status
8
Cerebral Palsy and Other Paralytic Syndromes
49
9
Chronic Hepatitis
Rheumatoid Arthritis and Inflammatory Connective Tissue
Disease
10
Chronic Obstructive Pulmonary Disease
50
Schizophrenia
11
Chronic Ulcer of Skin, Except Decubitus
51
Seizure Disorders and Convulsions
12
Cirrhosis of Liver
52
Severe Hematological Disorders
13
Coma, Brain Compression/Anoxic Damage
53
Specified Heart Arrhythmias
14
Congestive Heart Failure
54
Spinal Cord Disorders/Injuries
15
Cystic Fibrosis
55
Traumatic Amputation
16
Decubitus Ulcer of Skin
56
Vascular Disease
17
Diabetes with Neurologic or Other Specified Manifestation
57
Vascular Disease with Complications
18
Diabetes with Ophthalmologic or Unspecified Manifestation
19
Diabetes with Renal or Peripheral Circulatory Manifestation
20
Diabetes without Complication
21
Dialysis Status
22
Disorders of Immunity
23
Drug/Alcohol Dependence
24
Drug/Alcohol Psychosis
25
End-Stage Liver Disease
26
Extensive Third-Degree Burns
27
Hemiplegia/Hemiparesis
28
Inflammatory Bowel Disease
29
Lung, Upper Digestive Tract, and Other Severe Cancers
30
Lymphatic, Head and Neck, Brain, and Other Major Cancers
31
Major Complications of Medical Care and Trauma
32
Major Depressive, Bipolar, and Paranoid Disorders
33
Major Organ Transplant Status
34
Metastatic Cancer and Acute Leukemia
35
Multiple Sclerosis
36
Muscular Dystrophy
37
Nephritis
38
Opportunistic Infections
39
Pancreatic Disease
40
Paraplegia
41
Parkinson’s and Huntington’s Diseases
70
Table 2a. Acceptable Specialty Types for Risk Adjustment Data Submission
ALLERGY
GASTROENTEROLOGY
NEUROLOGY
PHYS MED/REHAB
ANESTHESIOLOGY
GENERAL HOSPITAL
NEUROSURGERY
PHYSCN ASSISTANT
APRN
GENERAL PRACTICE
NON-SUBMIT PROVDR
PHYSICAL THERAPY
AUDIOLOGY
GERONTOLOGY
NURSE PRACTITIONE
PODIATRY
CARDIAC REHAB
HB AMB SURG CNTR
OB/GYN
PSYCHIATRY
CARDIOLOGY
HB DIALYSIS FACIL
OCCUP THERAPY
PSYCHOLOGY
CHILD PSYCHIATRY
HOME HEALTH AGEN
ONCOLOGY
PULMONARY DISEASE
CHIROPRACTOR
HOME IV THERAPY
OPHTHALMOLOGY
RHEUMATOLOGY
CLINIC
HOSP OUTPT MEDICL
OPTOMETRY
SLEEP MEDICINE CLINIC
CLINIC EMERG SVCS
HOSPICE
OSTEOPATHY
SOCIAL WORKER
CLINIC PSYCH
HOSPITAL PSYCH
OTHER
SPEECH LANG PATH
CRNA
IN VITRO
OTHER FS FACILITY
SPEECH THERAPY
DERMATOLOGY
INFECT DISEASES
OTOLARYNGOLOGY
SUBSTANCE ABUSE
DIET/NUTRTNL PROF
INTERNAL MEDICINE
OUTPT CLINIC SVCS
SURGERY
EMERGENCY MED
LONG TERM CARE
PATHOLOGY
SURG-ORAL
ENDOCRINOLOGY
MARRGE FAM THRPST
PED NEUROLOGY
SURG-ORTHOPEDIC
FACILITY SERVICES
MENTAL HLTH CNSLR
PED ONCOLOGY
SURG-PLASTIC
FAMILY PHYSICIAN
MIDWIFE
PED SPECIALIST
URGENT CARE CLINIC
FS AMB SURG CNTR
NEPHROLOGY
PEDIATRICS
UROLOGY
FS DIALYSIS FACIL
Table 2b. Acceptable Facility Bill Types for Risk Adjustment Data Submission
011X
012X
013X
041X
071X
073X
074X
075X
076X
011X
085X
71
Well-Child Visits in the
First 15 Months of Life
COMMERCIAL • QUEST INTEGRATION
Well-Child Visits in the
Third, Fourth, Fifth, and Sixth Years
of Life
Description
COMMERCIAL • QUEST INTEGRATION
Percentage of patients who turned 15 months old during the
measurement period and who had six or more well-child visits
with a PCP during their first 15 months of life. This measure is
based on the Centers for Medicare & Medicaid Services (CMS)
and American Academy of Pediatrics guidelines for Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT) visits.
Description
Percentage of patients 3–6 years of age as of the end of the
measurement period who received one or more well-child visits
with a PCP during the measurement period. This measure is
based on the CMS and American Academy of Pediatrics
guidelines for EPSDT visits.
Refer to the American Academy of Pediatrics Guidelines for
Health Supervision at aap.org and Bright Futures: Guidelines for
Health Supervision of Infants, Children, and Adolescents
(published by the National Center for Education in Maternal and
Child Health) at brightfutures.org for more detailed information on
what constitutes a well-child visit.
Refer to the American Academy of Pediatrics Guidelines for
Health Supervision at aap.org and Bright Futures: Guidelines for
Health Supervision of Infants, Children, and Adolescents
(published by the National Center for Education in Maternal and
Child Health) at brightfutures.org for more detailed information
on what constitutes a well-child visit.
Numerator
Numerator
The six well-child visits must occur with a PCP, but the PCP
doesn’t have to be the provider assigned to the child. This
measure will use the billing codes from submitted claims to
identify well-child visits.
Children 3–6 years of age who received at least one well-child
visit with a PCP during the measurement period. The well-child
visit must occur with a PCP, but the PCP doesn’t have to be the
provider assigned to the child. This measure will use the billing
codes from submitted claims to identify well-child visits.
Please click the icon below for allowable numerator codes:
Please click the icon below for allowable numerator codes:
Denominator
Children who turned 15 months old during the measurement
period.
Denominator
Exclusions
Patients at least 3 years old and not more than 6 years old as of
the end of the measurement period.
Please click the icon below for allowable exclusion codes:
Exclusions
Please click the icon below for allowable exclusion codes:
Supplemental Data Option Documentation
Requirements
Supplemental Data Option Documentation
Requirements
To attest that a patient had a well-child visit, medical record
evidence of all of the following is required:
To attest that a patient had a well-child visit, medical record
evidence of all of the following is required:
• Health and developmental history (physical and mental).
• Physical exam.
• Health education/anticipatory guidance.
• Health and developmental history (physical and mental).
• Physical exam.
• Health education/anticipatory guidance.
In accordance with HEDIS definitions, the 15th month birth date will
be calculated as the patient’s first birthday plus 90 days.
Note: The annual well-child visit is generally scheduled every
12 months. HMSA recognizes that families and providers need
flexibility in scheduling well-child visits and will cover well-child
visits that are at least nine months apart.
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
72
Weight Assessment and
Counseling for Nutrition and
Physical Activity for Children/
Adolescents
Supplemental Data Option Documentation
Requirements
To attest that a patient had BMI percentile documentation,
counseling for nutrition, and counseling for physical activity,
medical record evidence of all of the following is required:
BMI
COMMERCIAL • QUEST INTEGRATION
• BMI percentile.
Description
• BMI percentile plotted on an age-growth chart.
Percentage of patients 3-17 years of age who had an outpatient
visit and who had evidence of the following during the measurement year:
Counseling for Nutrition
• BMI percentile documentation.***
• Discussion of current nutrition behaviors (e.g., eating habits,
dieting behaviors).
• Counseling for nutrition.
• Checklist indicating nutrition was addressed.
• Counseling for physical activity.
• Counseling or referral for nutrition education.
Numerator
• Member received educational materials on nutrition during a
face-to-face visit.
Patients age 3-17 years of age who had a recorded BMI,
counseling for nutrition, and counseling for physical activity from
their PCP. This measure will use the billing codes from submitted
claims to identify WCC credit.
• Anticipatory guidance for nutrition.
• Weight or obesity counseling.
Counseling for Physical Activity
Please click the icon below for allowable numerator codes:
• Discussion of current physical activity behaviors
(e.g., exercise routine, participation in sports activities,
exam for sports participation).
Denominator
• Checklist indicating physical activity was addressed.
Children 3-17 years of age who had an outpatient visit during the
measurement period.
• Counseling or referral for physical activity.
• Member received educational materials on physical activity
during a face-to-face visit.
Please click the icon below for allowable denominator codes:
• Anticipatory guidance specific to the child’s physical activity.
• Weight or obesity counseling.
Exclusions
Please click the icon below for allowable exclusion codes:
* Note: The codes listed in links and under various headings in Appendix A: Pay-for-Quality Measure Detail are a summary set for each
measure and don’t comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to
HEDIS specifications.
*** Because BMI norms for youth vary with age and gender, this measure evaluates whether the BMI percentile is assessed rather than
an absolute BMI value.
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Appendix B - Patient Attribution Process
1. K
eep the PCP selection for the patients who have selected a
PCP.
The patient attribution process aims to reflect our members’
preference for a provider as a PCP based on their office visit
pattern. HMSA’s HMO and QUEST Integration members are
included in the PCMH patient panel of the PCP they selected
upon enrolling. All other HMSA members are attributed to a PCP
based on the provider they’ve seen most frequently or most
recently, based on a review of HMSA claims for a
specified period.
2. F
or all other patients, attribute them to a PCP using a
16-month claims window. (A 37-month claims window was
used for the initial attribution.) For eligible PCP specialties, the
claims used represent face-to-face encounters between the
provider and patient.
3. S
elect the PCP who was most frequently seen or, in cases of a
tie, most recently seen.
The attribution process includes members of HMSA plans
including HMO and PPO plans, HMSA QUEST Integration, HMSA
Akamai Advantage plans, and The HMSA Children’s Plan.
4. Confirm that the patient has valid eligibility for that month.
An initial attribution using the process described as follows was
completed when HMSA launched its PCMH and pay-for-quality
programs. Thereafter, the same attribution process has been
completed after the close of every calendar month after HMSA
has posted all the claims processed and eligible members for
that month.
If there’s no change to the attribution for a patient, the previous
month’s attribution results will apply for the current month.
Attribution results will be available as an updated patient list on
Cozeva. Providers are encouraged to view their patient lists and
follow the update process described on Cozeva.
Providers may add patients to their patient lists through Cozeva.
Providers will need to sign an attestation to complete the
process. Their attestations will supersede claims-based
attributions.
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