Primary Care Provider Guidelines

Encounter. An encounter is a PCP or Specialist interaction with a member where a billable service is provided. These interactions are submitted by the Provider to the IPA who, in turn, submits the information to the appropriate Health Plan.

These encounters are tallied by each of the health plans and reported back to the IPA in the form of a score (average encounter per member per year). Each health plan has a minimum score the IPA must reach to be a part of the Pay for Performance Program. If a score is too low, the IPA is immediately excluded from the program.

In addition to counting the number of encounters submitted, the Health Plans have requirements in regards to the quality of information sent by the IPA. All encounters must be submitted in a timely fashion (90 days from the date of service) and must be coded correctly with the appropriate procedure or E&M code as well as the correct diagnosis code. Miscoded encounters are not included in Pay for Performance scoring.

Exclusions. Some measures allow us to exclude members from the eligible population identified as having a certain procedure or co-morbidity such as:

Breast Cancer Screening Exclude women who had:

·         Bilateral Mastectomy

·         Unilateral Mastectomy (members must have 2 separate occurrences on 2 different dates of service)

Cervical Cancer Screening Exclude women who had one of the following:

·         history of cervical cancer or HIV

·         a diagnosis of dysplasia, HPV or

·         abnormal pap test in the past five years

Colorectal Cancer Screening Exclude members who had one of the following:

·         a diagnosis of Colorectal Cancer

·         total colectomy

Please report any exclusions to the IPA by faxing list to (562) 663-8845.

The following criteria are used to identify eligible Pay for Performance patients:

CARDIOVASCULAR
Annual Monitoring for Patients on Persistent Medications Members 18 years of age and older who received at least a 180 treatment days of ambulatory medication therapy for agents listed, during the year and at least one monitoring event during the year:

·         Members on digoxin

·         Members on ACE

·         Members on diuretics

Cholesterol Management for Patients with Cardiovascular Conditions (LDL Screening and Control) Members 18-75 years of age who had a LDL-C screening and the level of control (<100 mg/dL) during the year
DIABETES
Diabetes Care Members 18-75 years of age with DMI or DMII who had the following done during the year:

·         HbA1c testing (>9.0%, <8.0%, <7.0%)

·         LDL-C screening (<100 mg/dL

·         Nephropathy monitoring (MicroAlbumin)

·         Retinal or dilated eye exam

·         BP Control (<140/90mm hg)

MUSCULOSKELETAL
Use of Imaging Studies for Low Back Pain (LBP) Members with a primary diagnosis of low back pain who did not have an imaging study (plan X-ray, MRI, CT scan) within 28 days of the diagnosis.
PREVENTION
Breast Cancer Screening (Mammogram) Women age 40 - 74 years old who had a mammography screening within the current year and the year prior
Evidence-based Cervical Cancer Screening (CC) Women *21 years of age and older who had the appropriate number of pap tests according to evidence-based guidelines:

·         Women 24-65 years who have not had a hysterectomy who had a single Pap test during the year or two years prior

·         Women 24-65 years of age with hysterectomies who had no Pap tests subsequent to their hysterectomy during the year or two years prior

·         Women 67 years and older who had no Pap tests during the year

*Guidelines are based on a normal screening result.

Childhood Immunizations (CI) Children 2 years of age who were identified as having completed the following antigen series by their second birthday:

4 DTap, 3 IPV, 1 MMR, 3 HiB, 3 HepB, 1 VZV, 4 PCV, 1 HepA, 2 or 3 rotavirus

Chlamydia Screening Women 16-24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the current year.
Colorectal Cancer Screening Adults 50-75 years of age who had an appropriate screening for colorectal cancer (CRC).

·         FOBT (during the year)

·         Flexible Sigmoidoscopy (during the year or the 4 years prior)

·         Colonoscopy (during the year or the 9 years prior)

Immunization for Adolescents Adolescents 13 years of age who were identified as having completed the following antigen by their 13th birthday:

·         1 Meningococcal

·         1 Tdap of Td

RESPIRATORY
Asthma Medication Ratio Members 5-50 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medication of .50 or greater during the measurement year
Appropriate Testing for Children with Pharyngitis (CWP) Children 2-18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
Appropriate Treatment for Children with Upper Respiratory Infection (URI) Children 3 months-18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) Adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.