Answers to Frequently Asked Questions Comprehensive Quality & Risk Program

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1 Answers to Frequently Asked Questions Comprehensive Quality & Risk Program What is the Comprehensive Quality & Risk Program? The Comprehensive Quality & Risk Program is a chronic conditions quality of care program that focuses on members with chronic conditions whose care and coding gaps need to be assessed. Is there any documentation that needs to be completed as a result of the Comprehensive Quality & Risk Program? Yes. Florida Blue is requesting you use our Comprehensive Quality & Risk Health Assessment Form for each identified Florida Blue member. We recommend you use the date of service that ties to the most comprehensive visit for the year during which any chronic conditions would likely have been assessed. This will give Florida Blue the most holistic view of the patient for quality of care and case management purposes. What is the purpose of the Comprehensive Quality & Risk Health Assessment Form? The Comprehensive Quality & Risk Health Assessment Form is designed to assist physicians in identifying, collecting and documenting the patient s condition(s) and closing any coding gaps. Is it a Florida Blue requirement that I attach the progress note in order for the Comprehensive Quality & Risk Health Assessment Form to be submitted? Yes, as of July 18, 2016, Florida Blue requires the progress note supporting all of the ICD-10 diagnosis codes be attached in order to submit the form. This requirement allows us to comply with CMS guidelines. Florida Blue must receive the medical record associated with the date of service on the form; the convenience of attaching it with the form prevents having to comply with a medical record request from Florida Blue later in the year. What criterion establishes a member for a health assessment form? Florida Blue identifies Medicare Advantage HMO and PPO and Qualified Health Plan members about whom we have the least information regarding quality, care, and risk of their current health status. Depending on the product in which the member is enrolled, they are either assigned to a Primary Care Physician (PCP) based on member selection or attributed to a physician most likely to be the PCP as reflected by claims data. Each identified member will have an associated Comprehensive Quality & Risk Health Assessment Form populated with dropped and suspected conditions available to the assigned or attributed physician. These conditions are associated with historical claims data received by Florida Blue within the last 24 months. How is the Comprehensive Quality & Risk Health Assessment Form accessed? The Comprehensive Quality & Risk Health Assessment Form is available electronically through Payer Spaces in Availity 1 at availity.com. 1

2 How can I access the Comprehensive Quality & Risk Health Assessment Form? You must have the proper permissions as an Availity user to access the Comprehensive Quality & Risk Health Assessment Form. To gain access, contact your Primary Access Administrator (PAA). To find your administrator's contact information in the Availity Web Portal, click your account option in the navigation bar, and then click Who controls my access? Will Florida Blue mail the health assessment form? No. The Comprehensive Quality & Risk Health Assessment Form is only available electronically through Availity by logging into availity.com and accessing Payer Spaces. What are the benefits of the Comprehensive Quality & Risk Health Assessment Form? The Comprehensive Quality & Risk Assessment Form is an easy-to-navigate web-based form that provides physicians with pre-populated patient information regarding chronic conditions and care and/or quality measures. The physician or practitioner will update this pre-populated form at least annually during a comprehensive examination of the patient. Electronic submission of the Comprehensive Quality & Risk Health Assessment Form ensures: Process consistency Efficient management of the member s health assessment Easy completion process and improves the quality of information collected Maintenance of document integrity and security Reduction of costly paper handling and manual routing I noticed pre-populated data in various sections of the Comprehensive Quality & Risk Health Assessment Form. What is the purpose of this data and where did it come from? The pre-populated member information in the form reflects information present in Florida Blue s enrollment files and diagnosis codes that have either been submitted previously but have not been confirmed during the current calendar year or are suspected based on claims data. Florida Blue has not independently confirmed that the pre-populated codes are currently accurate or clinically supported. You are responsible for independently evaluating whether the patient information is accurate based on your clinical assessment of the patient. If no diagnosis codes are pre-populated on the form, Florida Blue is looking to you to add any information you may have about the member to the form. This will assist us in engaging the member in quality of care and case management initiatives if needed. What is the logic that aligns a patient to a physician? Depending on the product in which the member is enrolled, Florida Blue either assigns a PCP based on member selection or a member is attributed to a physician based on claims data and the number of visits. How does Florida Blue assign members health risk assessment forms to providers at the provider group level? Florida Blue uses claims history to match member information with the provider identification number and tax identification number that aligns to the most correct organization within Availity. 2

3 Why do I sometimes have duplicate forms for the same patient? Florida Blue is always striving to help you have the most updated information on our members. When matching the member information with the provider identification number and tax identification number, if either identification number has been updated based on new claims received and a pending form already exists, you will receive a duplicate form with the most updated information Florida Blue has for that member. We do not remove existing pending forms based on these updates so as not to remove work that may have already been completed by our providers. The $150 reimbursement for completion of the assessment form is limited to one form per identified member per calendar year. Any duplicate forms will be accepted and the information will be captured; however, no reimbursement will be provided for subsequent forms after an initial form for a member is accepted for payment. Why did a patient s form disappear? When matching the member information with the provider identification number and tax identification number, if either identification number has been updated based on new claims received and the original form hasn t been opened, the original form will automatically be deleted and replaced with the updated form. If that patient has a more recent claim from a different provider, then that provider will receive the updated form. In addition, information that is pre-populated on the form will be updated throughout the year based on information Florida Blue receives via claims. What should I do with a duplicate form? Complete the form identified as Updated as it has the most updated information. Use the most comprehensive visit for the member to complete the form. For example, if a patient had a comprehensive physical last month and then sees you for a sinus infection this month, you might have two forms for the same member if the first one is in a pending status. Complete the updated form using information from the comprehensive physical visit as this is the visit that would most likely address any chronic conditions Florida Blue is looking to confirm for the current calendar year. What steps do I need to complete to fulfill Florida Blue s Comprehensive Quality & Risk Program requirements? 1. Contact patients who have been identified as part of the program to schedule an appointment. *If the patient has already been seen within the past 180 days, that date of service can be used to complete the form. 2. Complete an annual comprehensive assessment using the Comprehensive Quality & Risk Program Health Assessment Form, validating any pre-populated data and capturing any condition assessed or treated within the medical record. 3. Complete the Comprehensive Quality & Risk Health Assessment Form in its entirety, supportive to the face-to-face encounter. 4. Electronically sign and date the Comprehensive Quality & Risk Program Health Assessment Form with your credentials. 5. Electronically attach the medical record(s) associated with the date of service used to complete the form. 3

4 6. Electronically submit the Comprehensive Quality & Risk Assessment Form from Availity.com within 90 days of the date of service you have indicated on the form. 7. Submit a corresponding claim to Florida Blue with the appropriate coding for conditions documented within the medical record and captured on the health assessment form. How often do I need to see new patients? It is strongly encouraged you initiate a visit and complete the annual comprehensive assessment within 90 days of the member s assignment to the primary care physician. Am I required to complete a Comprehensive Quality & Risk Health Assessment Form every time I see an identified patient? No. Only one Comprehensive Quality & Risk Assessment Form should be completed once per calendar year based on a visit that includes a comprehensive assessment of the identified patient. Is there an additional payment for completing the Comprehensive Quality & Risk Health Assessment Form? In addition to regular office visit fees, Florida Blue will compensate you an additional $150 for using our assessment form, completing all fields of the health assessment form and submitting through Availity at Availity.com. There must be a corresponding claim filed to Florida Blue submitted supporting the date of service. How will the provider be reimbursed $150 for the completed and submitted Comprehensive Quality and Risk assessment? Once the electronic form is submitted and a corresponding claim with appropriate coding for condition(s) is documented within the medical record and captured on the assessment form, the $150 reimbursement to providers will be as an Electronic Funds Transfer (EFT) remittance advice, based on the providers contracted payment status (i.e., payee elected to receive an 835 electronic remittance or paper remittance advice). Payments are processed quarterly (90-day cycle) from the assessment submission date. What will the payment reconciliation look like and can a provider differentiate which patients are included in the payment? The payment is made as a credit memo and is reported as a PLB segment (Provider Level Adjustment) in the 835. PLB segments are not used to make claim payments. The code present on the 835 electronic remittance will indicate that it is a bonus (reason code: BN) along with the patient account number and date of service related to the claim for which the reimbursement payment is being made. The 835 paper remittance advice is a credit memo and not a claim. The reason code QRPMR (Reimbursement for performing a Comprehensive Quality Risk Assessment) will be displayed on paper remittance to identify a $150 provider reimbursement payment. Please Note: A takeback is not built into the provider reimbursement payment process and should not be considered as such. A negative cash balance shown as -$150 appears when the cash account has a credit balance. 4

5 Why didn t I receive an electronic remittance advice explaining the provider reimbursement bonus payment? If a payment only includes bonus money and did not include payment for claims, you will not receive an ERA If we included your bonus in with your next scheduled claim payment, then your ERA and payment have the same check number. The patient account number and original claim DOS are included with the provider level adjustment segment, PLB. Can I submit a paper version of a completed Comprehensive Quality & Risk Health Assessment Form and still receive the additional payment of $150? Paper versions of a completed assessment form received will not be accepted for additional payment. Can I submit copies of medical records instead of completing the assessment form? Yes; however, for the program we are asking you use our Comprehensive Quality & Risk Health Assessment Form in addition to using your own forms and medical records and/or progress notes. You can attach the associated medical record(s) to the form before submitting it. Can I attach several different progress notes to support the ICD-10 diagnosis codes in the Comprehensive Quality & Risk Health Assessment Form I am submitting? No, CMS guidelines require that ICD-10 diagnosis codes being submitted in the assessment form are supported in clinical documentation for the single date of service identified on the form. What should I do if my EMR does not support exporting progress notes? If you are unable to attach the progress note to the assessment form you will not be able to submit the form. Please reach out to your Network Manager who will work with your assigned risk adjustment provider educator for planning alternative diagnosis code submission options. Can I upload medical records associated with the identified HEDIS/STARS care gaps to the Comprehensive Quality & Risk Health Assessment Form to close those gaps as well? As of June 19, 2017, you will no longer complete HEDIS/STARS care gaps on the CQRP form. You will now use the HEDIS form loaded in the HEDIS attestation work queue to upload the records supporting the care gaps you are closing for the member. For information on how to access the CQRP form, you can view the demo within the Availity webpage. Am I required to participate in the Comprehensive Quality & Risk Program? No. You are not required to participate in the program, but are encouraged to do so. 5

6 What if I am not going to be submitting the assessment form but need to submit a supplemental diagnosis code for a condition that was addressed on the health assessment form but did not get included on the corresponding claims? Submit a second, original claim and use procedure code Florida Blue can accept either a zero charge or a penny charge on this created line. Check your software to determine if a zero charge can be billed. If the claim is electronic, use frequency Code 0. This procedure code will deny as incidental to the procedure code submitted on the primary claim therefore no payment will apply. (The advantage of billing with a zero charge is that there is no reconciliation on the outstanding balance of a penny for providers.) DO NOT submit a corrected claim Frequency Type 7. A corrected claim tells us the original claim was wrong and we will recover on the original claim with valid charges and pay the penny claim instead. Please ensure that claims data being submitted to clearinghouses are not inadvertently undergoing removal or exclusion of diagnosis codes prior to being submitted to Florida Blue. Complete and accurate code submission is vital to ensure you are getting proper credit for program and/or contractual requirements. Who do I contact for additional information regarding the program, including questions regarding reimbursement for assessment forms? Please send any questions regarding reimbursement for Risk Assessment forms to PRPPaymentInquiries@floridablue.com. Who do I contact for questions regarding the Comprehensive Quality & Risk Health Assessment Form? For information on how to access and complete the form, view the demo within the Availity webpage ( Contact Availity Customer Support at 1 (800) Who do I contact for questions regarding Availity? Contact Availity Customer Support at 1 (800) Availity, LLC is a multi-payer joint venture company. Visit availity.com to register. 6