Highmark Inc ENHANCED ANNUAL WELLNESS VISIT (eawv) PROGRAM MANUAL

Transcription

1 Highmark Inc ENHANCED ANNUAL WELLNESS VISIT (eawv) PROGRAM MANUAL January 2018

2 Table of Contents Section 1: Overview... 3 Section 2: Program Process... 3 Section 3: Participation... 5 Section 4: AWV Program Members and Impact... 5 Section 5: Data and Reporting... 5 Section 6: Program Compensation... 5

3 ENHANCED ANNUAL WELLNESS VISIT PROGRAM MANUAL Section 1: Overview The goal of Highmark Inc. s, including its subsidiaries and affiliates (hereinafter collectively, Highmark ), Enhanced Annual Wellness Visit Program (hereinafter, Program ) is to ensure that quality healthcare is provided to Highmark Medicare Advantage (MA) members (hereinafter, Program Members ) by conducting an eligible wellness visit on an annual basis. The expectation is that the PCP will reach out to the Program Member to schedule an Annual Wellness Visit (AWV), Subsequent Annual Wellness Visit (SWV) or Initial Preventive Physical examination (IPPE) (hereinafter, Visit ) during the current calendar year. Please note that the Visit is a covered benefit for the Program Member. This Program will encourage participating Practices (hereinafter, "Participants ) to perform Visits for all eligible Program Members. Each Visit must be precisely documented and accurately coded in the Highmark approved tool and Visit documentation should be filed in the Program Member's permanent medical record to ensure a complete picture of the Program Member s health for purposes of appropriate treatment and follow-up care. The participants will have the potential to receive program compensation (hereinafter, Program Compensation ) for performing the Visit using the Highmark approved tool. Section 2: Program Process This Program will launch on January 1, 2018 and concludes on January 18, 2019 for dates of service occurring between January 1 and December 31, Participant schedules an appointment with eligible Program Members. 2. When the Program Member presents for the scheduled appointment, the Participant completes the appropriate Visit using the Highmark approved tool following the instructions

4 for completion and submission. The Visit must be documented in the tool while the member is present for Visit. 3. The Participant ensures the Program Member s documentation is updated in the approved tool appropriately with all of the diagnosis codes listed on the D Tab being Monitored, Evaluated, Assessed and/or Treated (MEAT) during the Visit. 4. The Participant submits a claim with one of the following HCPCS codes: G Annual Wellness Visit (AWV) initial visit G Subsequent Annual Wellness Visit (SWV), subsequent visit G Initial Preventive Physical Examination (IPPE); face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment Participant also submits all appropriate procedure and diagnosis codes captured during the Visit on the claim. 5. Participant ensures that the assessment performed in the tool is incorporated into the Program Member s permanent medical record within 10 days of the Visit. 6. Highmark will perform a reconciliation of the vendor report showing what Visits were performed against the claims submitted to ensure accuracy. 7. Highmark will render program compensation for all completed Visits per the validation rules (See Section 6). 8. Highmark reserves the right to audit the Participants' medical records to ensure compliance with all requirements needed to support this Program. In the event the Participant has not met all Program requirements, including but not limited to, the medical record does not substantiate the level of codes billed, Highmark, in its sole discretion, may require Participant to immediately repay any Program Compensation related to such failure to comply with the Program requirements.

5 any Program questions you may have to your Highmark Provider Relations Representative or Clinical Transformation Consultant. Section 3: Participation As a condition of participation, all Participants will have, in effect, all contractual documents as required by Highmark, in its sole discretion. Section 4: AWV Program Members and Impact Highmark and the Participant, as applicable, agree that individuals participating in Highmark s MA products (including, but not limited to, HMO and PPO), with Highmark as their primary insurance carrier, are covered as Program Members pursuant to the Program. Highmark may require other Program criteria which will be set forth in an appropriate agreement or the Enhanced Annual Wellness Visit Program Manual, as applicable. Highmark may terminate the program in its sole discretion at any time. Section 5: Data and Reporting Participants will be able to view performance reports by logging into the approved tool and searching for the appropriate report within the report functionality. Program Compensation reports will be published on the Quality Blue user interface via NaviNet in conjunction with the Program Compensation payments on a quarterly basis. Section 6: Program Compensation Participants will receive additional Program Compensation as listed below, for successfully completing the following three requirements:

6 Fully complete the Visit via the approved tool as outlined in the training manual Submit a claim reflecting the information gathered during the Visit including the correct HCPCS (See Section 2) and diagnosis codes identified ensure all documentation from this visits is contained in the Program Member s permanent medical record Program Compensation of $125 per completed Visit performed between January 1, 2018 and December 31, Payments will be made quarterly as a separate payment administered to the Participant in the same manner as other Highmark payments are made. The payment schedule is as follows*: In May 2018, Participants will receive payment for Visits completed between Program launch and March 31, 2018 In August 2018, Participants will receive payment for Visits completed between April 1 and June 30, 2018 in addition to any Visits prior to April 1 that were not paid in the first quarter payment In November 2018, Participants will receive payment for Visits completed between July 1 and September 30, 2018 in addition to any Visits prior to July 1 that were not paid in the first or second quarter payment In March 2019, Participants will receive payment for Visits completed between October 1 and December 31, 2018 in addition to any Visits prior to October 1 that were not paid in the first, second or third quarter payment In addition, Participants will be eligible to earn bonus compensation for completing eawvs for a significant percentage of their attributed Medicare Advantage population. Participants who complete eawvs for 60% or more of the attributed Medicare Advantage population will earn an additional $25 for each completed and paid eawv performed during the year.

7 Participants who complete eawvs for 75% or more of the attributed Medicare Advantage population will earn an additional $40 for each completed and paid eawv performed during the year. Bonus compensation will be calculated at the end of the 2018 program and paid to Participants at the same time as the fourth quarter payments are made. Participants of the eawv Program are eligible for bonus compensation for this program only and not eligible for bonus compensation under the UDC Program. Attributed membership will be based on the number of members attributed to your practice as of April 1, 2018 thus making this number the denominator in the calculation of the bonus. Percentage Complete = Number of eawvs Completed and Program Compenstion Paid Attributed Membership as of April 1, 2018 If a Participant completes an Unconfirmed Diagnosis Code (UDC) Form for a Program Member first and later in the year completes an Enhanced Annual Wellness Visit for the same Program Member, the Participant will not receive Program Compensation for the eawv Program. The participant will only be paid the UDC Program Compensation for that member per the 2018 UDC Program Manual. If a Participant completes an Enhanced Annual Wellness Visit for a Program Member first and later in the year completes a UDC Form for the same Program Member, the Participant will only be reimbursed for the Enhanced Annual Wellness Visit at the base compensation level. For additional information, please refer to the 2018 Unconfirmed Diagnosis C ode (UDC) Program Manual. *The payments may be subject to delay depending on volume and operational processing times.