20-553 Earn Incentives through the Prop 56 VBP Program

Email:

HNCA_W9_Submissions@CENTENE.COM

(Add the words “Prop 56 W9” in the subject line.)

Fax:

1-833-794-0423

(Include a cover sheet and clearly add the words “Prop 56 W9” )

Email:

HNCA_W9_Submissions@CENTENE.COM

(Please note this is a document procurement email only, and is not monitored by an individual.)

Fax:

1-833-794-0423

Please list providers with the same TIN and the individual (Type 1) NPI below.

(If needed, add additional providers on a separate page and send in with the W-9.)

Date: __________________

PCP name (print): ___________________________________________________

PCP individual (Type 1) NPI: __________________________________________

PCP name (print): ___________________________________________________

PCP individual (Type 1) NPI: __________________________________________

PCP name (print): ___________________________________________________

PCP individual (Type 1) NPI: __________________________________________

PCP name (print): ___________________________________________________

PCP individual (Type 1) NPI: __________________________________________

PCP name (print): ___________________________________________________

Add-on directed payment amounts for members who are…

Categories

Measure

Non-at-risk

At-risk

Prenatal/postpartum care bundle

Prenatal pertussis (‘whooping cough’) Tdap vaccine

$25.00

$37.50

Prenatal care visit

$70.00

$105.00

Postpartum care visits

$70.00

$105.00

Postpartum birth control

$25.00

$37.50

Early childhood bundle

Well child visits in first 15 months of life

$70.00

$105.00

Well child visits in 3rd – 6th years of life

$70.00

$105.00

All childhood vaccines for two year olds

$25.00

$37.50

Blood lead screening

$25.00

$37.50

Dental fluoride varnish

$25.00

$37.50

Chronic disease management bundle

Controlling high blood pressure

$40.00

$60.00

Diabetes care

$80.00

$120.00

Control of persistent asthma

$40.00

$60.00

Tobacco use screening

$25.00

$37.50

Adult influenza ('flu') vaccine

$25.00

$37.50

Behavioral health integration bundle

Screening for clinical depression

$50.00

$75.00

Management of depression medication

$40.00

$60.00

Screening for unhealthy alcohol use

$50.00

$75.00

Email:

HNCA_W9_Submissions@Centene.com

(Add the words “Prop 56 W9” in the subject line.)

Fax:

1-833-794-0423

(Include a cover sheet and clearly add the words “Prop 56 W9” and “PROTECTED HEALTH INFORMATION.”)

Measure

Criteria

Prenatal pertussis (whooping cough) vaccine

Rendering or prescribing provider gives the Tdap vaccine during pregnancy

• Use Tdap CPT code 90715 with ICD-10 code ‘O09’ or ‘Z34’ series anytime in the measurement year (MY)
• Payment may only occur once per delivery per member MY
• Multiple births with different dates of service between January 1 through December 31 of the MY may count as twice

Note: This measure supports the Healthcare Effectiveness Data and Information Set (HEDIS^®) Prenatal Immunization Status measure.

Prenatal care visit

Rendering provider ensures initial prenatal visit

• Use CPT 992xx with ICD-10 code ‘O09’ or ‘Z34’
• Payment is for prenatal and preventive care on a routine, outpatient basis. Not intended for emergent events
• Only one payment per pregnancy per plan
• Payment is for the first visit in a plan at any time during the pregnancy

Note: This measure supports the Centers for Medicare and Medicaid Services (CMS) Child Core Set Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-CH).

Postpartum care visits

Rendering provider completes advised postpartum care visits after birth

• Use ICD-10 code Z39.2.
• Definitions for postpartum visit time periods:
  • Early: On or between one and 21 days after delivery
  • Late: On or between 22 and 84 days after delivery
• Delivery date is required to determine the timing of the visit (early or late). Payment is not specific to live births
• Payment to the first visit in the time period (early or late)
• Only one payment per time period (early or late)

Note: Incentive payments support the current American College of Obstetricians and Gynecologists (ACOG) recommendations regarding the two postpartum visits.

Postpartum birth control

Rendering or prescribing provider uses a birth control method within 60 days of delivery

• Codes used to calculate this measure are available on the Medicaid website in tables CCP-C through CCP-D¹
• Delivery date is required to determine the timing of the visit. Payment is not specific to live births
• Use of most effective method of birth control, moderately effective method, or long-acting reversible method of contraception
• Payment to the first occurrence of contraception in the time period
• Only one payment per delivery

Note: This measure supports the Centers for Medicare & Medicaid Services (CMS) Child and Adult Core Set Measures Contraceptive Care - Postpartum Measures (CCP-CH) (ages 15-20) and (CCP-AD) (ages 21-44).

Measure

Criteria

Well-child visits, first 15 months of life

Separate payments to rendering provider for completing each of the last three visits out of eight total (6th, 7th and 8th)

• Use the appropriate listed CPT and ICD-10 codes:
  • CPT: 99381–99385, 99391–99395, 99461, G0438–G0439
  • ICD-10: Z00.00–Z00.01, Z00.110–Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.82, Z76.1-Z76.2
• Separate incentive payments to a provider for each of the last three well child-visits out of eight total – 6, 7 and 8 (8 visits are recommended between birth and 15 months using the recommendation from the American Academy of Pediatrics (AAP)).
• Three payments per child are eligible for payment – ages 6, 9 and 12 months

Note: This measure supports CMS Child Core Set Measure Well-Child Visits in the First 15 Months of Life (W15-CH).

Well-child visits, ages 3-6

Separate payments to rendering provider for completing each annual visit

• Use the appropriate listed CPT and ICD-10 codes:
  • CPT: 99381–99385, 99391–99395, 99461, G0438–G0439
  • ICD-10: Z00.00–Z00.01, Z00.110–Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0-Z02.6, Z02.71, Z02.82, Z76.1-Z76.2
• Separate payment to each rendering provider for successful completion for the first well-child visit in each year age group (ages 3, 4, 5, or 6)

Note: This measure supports CMS Child Core Set Measure Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34-CH).

All childhood vaccines for age 2

A provider may receive up to seven payments per year per member

• Pay an incentive payment to a provider when the last dose in any of the multiple dose vaccine series is given to children turning age two in the MY. A given provider may receive up to seven payments per year per member
  • Diphtheria, tetanus, pertussis (DTaP) – 4th vaccine
  • Inactivated polio vaccine (IPV) – 3rd vaccine
  • Hepatitis B – 3rd vaccine
  • Haemophilus influenza type b (Hib) – 3rd vaccine
  • Pneumococcal conjugate – 4th vaccine
  • Rotavirus – 2nd or 3rd vaccine
  • Flu – 2nd vaccine
• A two year look-back period is required for each member to capture the series of vaccines and identify the last vaccine in the series

Note: This measure supports the CMS Child Core Set Childhood Immunization Status (CISCH).

Blood lead screening

Rendering provider completes the screening in children up to age two

• Use CPT code 83655 for screenings done on or before the second birthday
• A provider can receive more than one payment
• Blood lead level (BLL) tests will not be excluded if a child is diagnosed with lead toxicity

Note: This measure supports the HEDIS measure Lead Screening in Children (LSC).

Dental fluoride varnish

Provider gives fluoride varnish to children ages 6 months through 5 years

• Use CPT code 99188 or dental code CDT D1206
• Payment to each rendering provider is for each occurrence of dental fluoride varnish for children under age 6
• Payment for the first four visits in a 12 month period

Measure

Criteria

Controlling high blood pressure (HBP)

Rendering provider documents each event of adequately controlled blood pressure for members ages 18-85 with a diagnosis of HBP

• Use the appropriate CPT codes for controlled systolic and diastolic pressure, with ICD-10 code I10 for essential hypertension

• Billing for a visit must include a code for the controlled systolic, diastolic and ICD-10 code I10 (essential hypertension) diagnosis on the same day
• For members age 18 to 85 at the time of the visit being seen for their diagnosis of HBP
• Payment to each rendering provider for a non-emergent outpatient visit, or remote monitoring event that documents controlled blood pressure

Note: This measure supports CMS Adult Core Set Controlling High Blood Pressure (CBP-AD).

Diabetes care

Rendering provider documents results of each event of HbA1c testing for members age 18 to 75

• Use the following CPT codes for each event of diabetes (HbA1c) testing (laboratory or point of care) that shows the most recent results:

Note: 3045F, through September 30, 2019; 3051F, as of October 1, 2019; 3052F, as of October 1, 2019.

• Diabetes diagnosis is not required to allow for screening of individuals at increased risk of diabetes
• Dates for HbA1c results must be at least 60 days apart
• No more than four payment are allowed per year

Note: This measure supports both CMS Adult Core Set measures HA1C-AD: Comprehensive Diabetes Care: Hemoglobin A1c (HA1C-AD) Testing and Hemoglobin A1c Poor Control (HPC-AD).

Control of persistent asthma

Provider monitors and prescribes controller asthma medication to members between ages 5 and 64 (at the time of visit) with a diagnosis of asthma

• Use the appropriate ICD-10 diagnosis codes for the Asthma Value Set:

• Payment to provider who has prescribed controller medications for each beneficiary between the ages of 5 to 64 years (at the time of the visit) with a diagnosis of asthma in the MY, or the year prior to the MY.
• Each provider is paid once per year per member

Note: This measure specification supports CMS Child and Adult Core Set measures Asthma Medication Ratio: Ages 5-18 (AMR-CH) and Ages 19-64 (AMR-AD).

Tobacco use screening

Provider screens or counsels members ages 
12 and older

• Use CPT codes: 99406-99407, 4004F, or 1036F
• Equivalent payment is for all CPT codes
• No more than one payment per provider per member per year
• Must be an outpatient visit

Note: This measure supports National Committee for Quality Assurance (NCQA) #226 (National Quality Forum (NQF) 0028). This measure also aligns with U.S. Preventive Services Task Force (USPSTF) recommendations for screening/counseling for tobacco in adolescents and adults.

Adult influenza (flu) vaccine

Provider ensures flu vaccine is given to members ages 19 and older

• Member must be age 19 or older at the time the flu vaccine is given
• Payments to rendering or prescribing provider is for up to two flu shots given through the year
• No more than one payment per member per quarter: First quarter (January–March) or the last quarter of the year (October–December)
• If more than one provider gives the shot in the same quarter, only the first provider gets paid in that quarter

Note: This measures supports the American Medical Association Physician Consortium for Performance Improvement (AMA-PCPI) NQF 0041 Preventive Care and Screening: Influenza Immunization.

Measure

Screening for clinical depression

Provider screens members ages 12 and older using a standardized screening tool

• Use CPT codes G8431 or G8510 for clinical depression
• Equivalent payment is for both CPT codes
• No more than one payment per provider per member per year
• Must be an outpatient visit

Note: This measure supports CMS Core Set measure Screening for Depression and Follow-up Plan:   Ages 18 and Older (CDF-AD).

Management of depression medication

Provider monitors members, ages 18 and older, diagnosed for major depression and newly treated with mediation

• Use major depression ICD-10 codes: F32.0–F32.4, F32.9, F33.0–F33.3, F33.41, F33.9
• Member must have remained on the new anti-depressant medicine treatment plan for at least 12 weeks
• Payment to prescribing providers is for the Effective Acute Phase Treatment where the diagnosis of major depression is 60 days before the new prescription through 60 days after
• Effective Acute Phase Treatment is at least 84 days during 12 weeks of treatment with antidepressant medication beginning on the index prescription start date (IPSD) through 114 days after the IPSD (115 total days)
• Payment goes to each provider that prescribed antidepressant medicine during the Effective Acute Phase Treatment period
• No more than one Effective Acute Phase Treatment per year
• Definitions
  • Intake: The 12-month period starting on May 1 of the year prior to the MY and ending on April 30 of the MY.
  • IPSD: The earliest prescription dispensing date for an antidepressant medication where the date is in the Intake Period and there is a Negative Medication History.
  • Negative medication history: A period of 105 days prior to the IPSD when the member had no pharmacy claims for either new or refill prescriptions for an antidepressant medication.
  • Treatment days: At least 84 days of treatment beginning on the IPSD through 114 days after the IPSD.
  • Antidepressant medication: NCQA’s Medication List Directory (MLD) of National Drug Codes (NDC) for Antidepressant Medications

Note: This measure supports the CMS Adult Core Set measure Antidepressant Medication Management (AMM-AD).

Screening of unhealthy alcohol use

Provider screens members ages 18 and older for unhealthy alcohol use with a standardized screening tool

• Use CPT codes 99408–99409, G0396–G0397, G0442–G0443, H0049, or H0050
• Equivalent payment is for all CPT codes
• Only one payment per provider per member per year
• Increased standardized screening will help identify and treat members with alcohol use disorders

Note: This measure specification supports Quality Identifier #431 (NQF 2152): Preventive Care  and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling. This measure also aligns with USPSTF recommendations about alcohol screening tools.