Provider Manual. Colorado Medicaid Accountable Care Collaborative RCCO Region 1 Western Slope and Larimer County

Transcription

1 Provider Manual Colorado Medicaid Accountable Care Collaborative RCCO Region 1 Western Slope and Larimer County WORKING TOGETHER TO DELIVER QUALITY HEALTH CARE Archuleta, Delta, Dolores, Eagle, Garfield, Grand, Gunnison, Hinsdale, Jackson, La Plata, Larimer, Mesa, Moffat, Montezuma, Montrose, Ouray, Pitkin, Rio Blanco, Routt, San Juan, San Miguel, Summit Counties

2 The Basics Medicaid Accountable Care Collaborative Program... 5 Accountable Care Collaborative Program... 5 Members and Regional Care Collaborative Organizations (RCCOs)... 5 Provider Network and Community... 5 Primary Care... 5 Claims and Authorizations... 5 Special ACC Initiatives... 5 Medicaid Accountable Care Collaborative (ACC) Program Intro RMHP Region 1 Western Slope and Larimer County. 6 What is the Accountable Care Collaborative (ACC) Program?... 6 What is a Regional Care Collaborative Organization (RCCO)?... 6 What is a Primary Care Medical Provider (PCMP)?... 6 What is the State Data and Analytics Contractor (SDAC)?... 6 What are the Goals of the Accountable Care Collaborative?... 7 Emergency Room Visits... 7 Inpatient Readmissions Within 30 Days... 7 High Cost Imaging... 7 Well Child Care... 7 Performance Measurement Areas... 8 Contracting with Department of Health Care Policy & Financing for the ACC Program... 8 What is the Structure of the Colorado ACC Program?... 8 What is a Medical Home... 9 Member Enrollment and Selection of Primary Care Medical Provider Who is eligible to enroll in the ACC program? Role of Statewide Data and Analytics Contractor Enrollment & Attribution ACC Member Enrollment with a Primary Care Medical Provider (PCMP) / PCMP Attribution Department PCMP Choice Form Fax Enrollment Form Getting Paid for the Accountable Care Collaborative Program Payments by Colorado Medicaid for Services Provided Prior Authorization Requests ColoradoPAR Program, administered by APS PAR Submission and CareWebQI Portal Paper PARs Payments to Primary Care Medical Providers Per Member Per Month Rate Table Incentive Payments Key Performance Indicator Breakout for Incentive Payments Data and Reports Statewide Data Analytics Contractor (SDAC) Overview of the SDAC Portal Structure Overview of the SDAC Portal Metrics Overview of the SDAC Portal Reports and Tools How to Access the SDAC Web Portal ii

3 Reports from Rocky Mountain Health Plans Annual Reports Monthly Reports Care Management Information Risk/Acuity-Based Levels of Care Coordination Level 1 Preventive care, wellness care Level 2 Single, well-managed chronic disease Level 3a - Moderately well-managed Disease Process (controlled and uncontrolled periods; referrals to specialists not required) Level 3b Moderately managed Disease Process (controlled and uncontrolled periods; referrals to specialists required) 20 Level 4 Complex Outpatient Care Coordination Poorly controlled disease process Level 5 Transitions of Care Care Coordination and Community Care Teams RMHP Region 1 Care Coordination by County RMHP ACC Member Dismissal Process Process for Dismissal of a RCCO Member Department-accepted reasons for dismissing an RCCO member: Other Helpful Information Portals to Verify Eligibility Sample Screenshots of the State s Medicaid provider portal Medicaid ACC / RCCO Member Unattributed to a PCMP Medicaid ACC / RCCO Member Attributed to a PCMP Medicaid ACC Member ID Cards Transportation Benefits Informational Website Links Appendix A RCCO Contact List RMHP Contacts and Resources Colorado Medicaid Provider Services ColoradoPAR Program, administered by APS Enrollment Broker for Enrollment and Doctor/Primary Care Provider Changes Ombudsman for Medicaid Managed Care Colorado Medicaid Nurse Advice Line Behavioral or Mental Health Services for Colorado Medicaid Clients Colorado Health Partnerships Northeast Behavioral Health Partnership Single Entry Point (SEP) Agencies Community Centered Boards (CCB) Appendix C Passive Enrollment Letter (Spanish) Appendix D Fax Enrollment Form Appendix E SDAC Dashboard Portal Access Request Form Appendix F PCMP Request for Dismissal Form iii

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5 The Basics Medicaid Accountable Care Collaborative Program Accountable Care Collaborative Program The Accountable Care Collaborative (ACC) program is a Colorado Medicaid initiative to improve clients health and reduce costs. The ACC program is a central part of Colorado s Medicaid reform that changes the incentives and health care delivery processes for providers from one that rewards a high volume of services to one that holds people accountable for health outcomes. Key performance indicators are tracked by participating practice and region. Members and Regional Care Collaborative Organizations (RCCOs) Most people who qualify for Medicaid in Colorado are eligible to enroll in the Accountable Care Collaborative program. Enrollment is through a passive enrollment process where people who qualify for the ACC receive a letter informing them of their enrollment. Each Member is enrolled with a Regional Care Collaborative Organization (RCCO) who helps the Member with care coordination, getting care, answering questions, and referring to other services. Rocky Mountain Health Plans is the Regional Care Collaborative Organization for Western Colorado and Larimer County. Other organizations serve as RCCOs in other regions. Provider Network and Community All State Medicaid providers can participate in the ACC. Providers are part of the Member s medical neighborhood, and are asked to communicate and coordinate care with the Member s primary care physician. For many services, protocols are developed with the RCCO that define how organizations and people will collaborate and communicate to serve the needs of ACC Members. ACC Members continue to receive behavioral health services through their Behavioral Health Organization. Primary Care Primary care practices play an important role in the ACC program. Practices receive an additional per member per month payment from the State of Colorado Department of Health Care Policy and Financing for their participation. To participate, a primary care practice needs to sign an agreement with the local Medicaid Regional Care Collaborative Organization (RCCO) and a Primary Care Medical Provider contract with the State of Colorado Department of Health Care Policy and Financing. The RCCO for Western Colorado and Larimer County is Rocky Mountain Health Plans. Claims and Authorizations Claims for Members in the ACC Program are submitted to Colorado Medicaid following Medicaid rules. Requests for Prior Authorizations are submitted to the ColoradoPAR Program following Medicaid rules. Special ACC Initiatives The ACC program includes some initiatives for target populations. Medicaid Payment Reform Initiative Medicaid Prime: This initiative brings payment reform, population health management, and whole-person care together within a community-based service delivery model in western Colorado. This initiative will begin in 2014 and the target population includes adults who qualify for Medicaid in seven counties in western Colorado: Delta, Garfield, Gunnison, Mesa, Montrose, Pitkin, and Rio Blanco. Colorado lawmakers authorized this effort through passage of House Bill , a bipartisan agreement to move toward a more cost-effective and accountable system of care. The Colorado Department of Health Care Policy and Financing reviewed proposals for an innovative payment reform initiative and selected a plan submitted by Rocky Mountain Health Plans. The provider network for Medicaid Prime includes RMHP s provider network, and claims are submitted to RMHP, except for long-term care services and services covered by the behavioral health organization. Information about this initiative is available at in RMHP s provider manual, and on the Department s website. Medicaid Demonstration to Integrate Care for Full Benefit Medicare and Medicaid Enrollees: Through the infrastructure and resources of the Accountable Care Collaborative Program, the Department of Health Care Policy and Financing is developing an initiative to better coordinate care for full benefit Medicare-Medicaid enrollees. Full benefit Medicare-Medicaid 5

6 enrollees are individuals who are enrolled in Medicare Parts A and B and eligible for Part D, receive full Medicaid State Plan benefits, receive or are eligible for Medicaid waiver services, and have no other comprehensive private or public health insurance. Individuals eligible for the demonstration are not enrolled in a Medicare Advantage or other Medicare plan. It is anticipated that this initiative will begin in This initiative includes strategies to meet the following objectives: Coordinate the health care, services and supports for full benefit Medicare-Medicaid enrollees by providing greater integration between the ACC Program, other Medicaid programs serving these enrollees, and the Medicare program. Improve transitions into and out of Long-Term Services and Supports to promote better health outcomes Improve integration of physical and behavioral health Make it easier for enrollees to understand benefits and access to care. Medicaid Accountable Care Collaborative (ACC) Program Intro RMHP Region 1 Western Slope and Larimer County What is the Accountable Care Collaborative (ACC) Program? The Accountable Care Collaborative (ACC) is a Colorado Medicaid program to improve clients health and reduce costs. Medicaid clients in the ACC will receive the regular Medicaid benefit package, and will also belong to a "Regional Care Collaborative Organization" (RCCO). Medicaid clients will also choose a Primary Care Medical Provider (PCMP). The ACC is a central part of the State of Colorado s Medicaid reform that changes the incentives and health care delivery processes for providers from one that rewards a high volume of services to one that holds them accountable for health outcomes. This section of RMHP s provider manual is specific to Colorado Medicaid s Accountable Care Collaborative Program. What is a Regional Care Collaborative Organization (RCCO)? The RCCO connects Medicaid clients to Medicaid providers and also helps Medicaid clients find community resources and social services in their area. The RCCO helps providers communicate with Medicaid clients and with each other, so Medicaid clients receive coordinated care. The RCCO also helps Medicaid clients get the right care when they are returning home from the hospital or a nursing facility by providing the support needed for a quick recovery. The RCCO helps with other care transitions too, like moving from children s health services to adult health services, or moving from a hospital to nursing care. Rocky Mountain Health Plans serves as the RCCO for Western Colorado and Larimer County (RCCO Region 1). What is a Primary Care Medical Provider (PCMP)? A primary care medical provider (PCMP) is the Medicaid ACC program main health care provider. A PCMP is a Medicaid client's medical home, where he/she will get most of their health care. When a Medicaid client needs specialist care, the PCMP will help him/her find the right specialist. All clients enrolled in the ACC have a PCMP. Requirements about criteria for participation as a PCMP for the ACC Program are defined by the Department of Health Care Policy and Financing. What is the State Data and Analytics Contractor (SDAC)? The Statewide Data Analytics Contractor (SDAC) is responsible for providing secure electronic access to clinically actionable data to the Regional Care Collaborative Organizations (RCCOs) and Primary Care Medical Providers (PCMPs) to help them meet the goals of the Accountable Care Collaborative (ACC). The SDAC helps RCCOs and PCMPs by allowing PCMPs and RCCOs to better coordinate Medicaid clients care by providing secure access to diagnoses, prescription, and other health information. They also provide reports to PCMPs and RCCOs to help eliminate avoidable and duplicative procedures. In addition, the SDAC analyzes claims to identify potentially preventable health events (e.g. ER visits, hospital readmissions). 6

7 The SDAC contract is held by Treo Solutions. They are responsible for: Building and implementing the ACC data repository Creating reports using advanced health care analytics Hosting and maintaining a Web Portal Fostering accountability and ongoing improvement among RCCOs and providers Identifying data-driven opportunities to improve care and outcomes What are the Goals of the Accountable Care Collaborative? By assisting Medicaid clients in getting connected to a PCMP as their Medical Home and by ensuring the medical, specialty, mental health care and other related services are well coordinated, clients experience in the health care system will improve. Clients will be the primary drivers of their healthcare decisions, but will have the support and assistance they need to achieve their personal healthcare goals. In addition, by having a primary source of medical care that attends to both sick care and wellness and prevention activities, the overall health of Medicaid clients will improve. Finally, when clients are more satisfied and empowered in their healthcare decisions and overall health improves, the total cost of care is reduced. Colorado has chosen to measure four specific health care activities as indicators of program success at this time. Those measures include: Emergency Room Visits: Medical care in an emergency room is costly, disruptive, and not always necessary for every condition. By helping Medicaid clients understand what alternatives they have for using the emergency room for non-emergent conditions, unnecessary use of emergency rooms will be reduced. Inpatient Readmissions Within 30 Days: Inpatient care is necessary for many healthcare conditions and circumstances, and as such is an essential component of the healthcare continuum. However, rapid readmission to inpatient care can often be avoided if Medicaid clients get the assistance they need from their PCMP to ensure timely post-discharge care to help them understand their discharge instructions and medications, and provide adequate supports to make a successful and sustained transition out of the hospital. High Cost Imaging: This refers to costly diagnostic procedures such as MRIs and CT scans. While these are valuable, necessary tools, they are often unnecessarily repeated when multiple providers are involved in a client s care. By ensuring better communication and coordination of care between providers, some of these duplicative services can be eliminated. Well Child Care: Effective July 1, 2013, HCPF began measuring a fourth measure, Well Child Visits, based on CMS- 416 criteria. Beginning in early 2014, HCPF will begin to provide financial incentive payments to RCCOs and PCMPs for this Key Performance Indicator (KPI). 7

8 Performance Measurement Areas The following table details the State of Colorado Department of Health Care Policy and Financing performance measures associated with the above healthcare costs and activities. Measurement Areas Emergency Room Visits per 1,000 full time enrollees (FTEs) Performance Target Level 1 Target: Utilization shows greater than 1.0% but less than 5.0% improvement. Level 2 Target: Baseline utilization minus 5.0% or more Hospital Readmissions per 1,000 FTEs Level 1 Target: Utilization shows greater than 1.0% but less than 5.0% improvement. Outpatient Service Utilization per 1,000 FTEs (MRI, CT scans, and X-ray tests) per 1,000 FTEs Well Child Visit: Children Aged 0-20 ACC Enrollment at least 90 days continuous. At least one Well Child Visit per 12-month period. Rolling 12- months Level 2 Target: Baseline utilization minus 5.0% or more Level 1 Target: Utilization shows greater than 1.0% but less than 5.0% improvement. Level 2 Target: Baseline utilization minus 5.0% or more Level 1 Target: 60%* Level 2 Target: 80%* *Of eligible children with at least one well-child check within the year Contracting with Department of Health Care Policy & Financing for the ACC Program To participate as a Primary Care Medical Provider in the Accountable Care Collaborative program, primary care providers must complete a PCMP Agreement with the RCCO serving their community and with the State of Colorado. Primary care providers in Region 1 (area shown below) therefore sign a PCMP agreement with both RMHP and the State. Primary care providers with locations in several RCCO regions need to only sign a contract with one RCCO. The State version of the contract, including the opt-in process for amendments to the contract, can be completed on-line. Completing HCPF ACC Contract For further information regarding the contracting process, call RMHP Provider Relations: What is the Structure of the Colorado ACC Program? Under the Medicaid ACC program, the state is divided into seven regions to account for the differing health needs of geographically diverse communities. There is a Regional Care Collaborative Organization (RCCO) for each region. The RCCO helps coordinate care of those ACC Members living within their region. Rocky Mountain Health Plans is the RCCO for Region 1, which includes western slope counties and Larimer County. 8

9 What is a Medical Home A medical home is where a primary care physician and the patient make medical decisions and are supported by a health plan that is focused on coordinated care and innovation. Setting up a partnership with a personal doctor is a vital step in managing a patient s health care. Primary Care Providers (PCPs) can provide preventive care, serve as a guide for patients when making decision on the need of specialty care, and help avoid unnecessary medical expenses. The time for an individual to establish a relationship with a PCP is when that individual is healthy, instead of waiting until he or she is sick or injured and in need of medical care in a hurry. RMHP encourages every Member to select a personal Primary Care Provider. The following are the principles of the Medical Home Model as defined by the State of Colorado s Department of Health Care Policy and Financing for the Accountable Care Collaborative program. The care provided is: Member/family-centered Whole-person oriented and comprehensive Coordinated and integrated Provided in partnership with the Member and promotes Member self-management Outcomes-focused 9

10 Consistently provided by the same provider as often as possible so a trusting relationship can develop Provided in a culturally competent and linguistically sensitive manner Primary care medical providers are: Accessible, aiming to meet high access-to-care standards such as: o 24/7 phone coverage with access to a clinician who can triage o Extended daytime and weekend hours o Appointment scheduling within: 48 hours for urgent care 10 days for symptomatic, non-urgent care 45 days for non-symptomatic routine care o Short waiting times in reception area o Committed to operational and fiscal efficiency Able and willing to coordinate with its associated RCCO on medical management, care coordination and case management of Members Committed to initiating and tracking continuous performance and process improvement activities, such as improving tracking and follow-up on diagnostic tests, improving care transitions, and improving care coordination with specialists and other Medicaid providers, etc. Willing to use proven practice and process improvement tools (assessments, visit agenda, screenings, Member selfmanagement tools and plans, etc.) Willing to spend the time to teach Members about their health conditions and the appropriate use of the health care system as well as inspire confidence and empowerment in Members health care ownership Focused on fostering a culture of constant improvement and continuous learning Willing to accept accountability for outcomes and the Member/family experience Able to give Members and designated family members easy access to their medical records when requested Committed to working as a partner with the RCCO in providing the highest level of care to Members. Member Enrollment and Selection of Primary Care Medical Provider Passive Enrollment is the term used to describe how Medicaid clients are enrolled in the ACC Program. Medicaid clients eligible for enrollment in the ACC Program receive a letter advising them of their enrollment. Passive enrollment refers to the fact that a Member must choose to decline participation in the program, or, opt out. The client has 30 days from the date of the Passive Enrollment letter to opt out. If the client takes no action to decline participation, the client is automatically enrolled. Members do not need to do anything if they wish to remain in the program. Once enrolled, a new Member has 90 days after enrollment to disenroll. HealthColorado is the Enrollment Broker that assists Members with enrollment in the ACC Program, and with selecting or changing a PCMP. Each month HealthColorado sends out letters to Members that have been selected for passive enrollment in the ACC Program. This passive enrollment letter includes the name and contact information for the RCCO in which the client is enrolled (based on where the client lives), and the name of the provider (group practice, clinic, Federally Qualified Health Center, etc.) that will be the client s Primary Care Medical Provider, if one has been identified. The Member must call HealthColorado if he or she wants to select another Primary Care Medical Provider or if the Member wants to opt out of the program. If the member has no clear connection to a PCMP as determined by the Department s attribution process, the Passive Enrollment letter will indicate that the Member needs to call HealthColorado to select a PCMP. 10

11 Members receive a current RCCO Primary Care Medical Provider (PCMP) Directory and a RCCO Member Handbook when they receive the Passive Enrollment letter. The PCMP Directory lists all contracted PCMPs from which the Member may make his or her PCMP selection. The Member Handbook provides detailed information about the ACC program. RMHP and PCMPs may not make the call to the enrollment broker on behalf of the Member, but can assist the Member in making the call. See Appendix B and Appendix C to see sample copies of the Passive Enrollment Letter. Who is eligible to enroll in the ACC program? Only clients currently eligible for Medicaid are able to enroll in the ACC program. Clients may gain and lose eligibility many times in a given year. Therefore, a patient who is on a practice s patient panel for one month may not be on the practice s panel the following month due to no longer being eligible for Medicaid. Most people who qualify for Medicaid are eligible for enrollment in the ACC program, however, certain clients are not being enrolled into the ACC program at this time, e.g., clients enrolled in a Medicaid managed care program, clients residing in an institutional setting. Role of Statewide Data and Analytics Contractor Enrollment & Attribution The Statewide Data and Analytics Contractor (SDAC), Treo Solutions, is responsible for identifying clients eligible for enrollment into the ACC program and for conducting the Department of Health Care Policy and Financing s attribution process to identify if an ACC Member is attributable to a Primary Care Medical Provider based upon claims history. ACC Member Enrollment with a Primary Care Medical Provider (PCMP) / PCMP Attribution An important element of the ACC Program is to identify a Primary Care Medical Provider for each Member, and to encourage each Member to establish a primary care medical home. The Department of Health Care Policy and Financing s objective with Member-PCMP attributions is to maintain existing client-provider relationships. To meet this objective, the Department developed an attribution methodology to identify prior Medicaid client and primary care practice history based on State Medicaid records and claims history. To identify if a Medicaid client has an existing relationship with a PCMP, the Department s attribution process takes into account such factors as location, claims history and frequency, PCMP participation, and if necessary, the timeframe of the claims history with a particular PCMP. The Department strives to maintain existing relationships with PCMPs whenever possible, including keeping a family (e.g. mother and children) assigned to the same provider whenever possible. The Statewide Data and Analytics Contractor conducts the Department s attribution process by analyzing a client s past 12 months of Medicaid claims (24 months if no 12-month claim history is found) for Evaluation & Management (physician) codes to determine the medical provider the client has seen most frequently. This process has one of four outcomes: The client has a clear pattern of using one primary care provider and the provider is participating in the ACC. In this scenario, the client is enrolled into the program with the identified provider as the client s PCMP. The client has a clear pattern of using one primary care provider but the provider is not participating in the ACC. In this scenario, the client is not enrolled into the ACC program. The client has a clear pattern of using two or more providers equally. In this case, the client is connected to the provider visited most recently. If this provider is participating in the ACC program, the client will be enrolled into the ACC program with that provider as the PCMP. The client has no clear pattern of using any primary care provider. In this case, if the client has a family member with an identified PCMP, the client is enrolled into the ACC program with that PCMP. If the client does not have a family member with a PCMP, he or she is enrolled in the ACC without a PCMP and given the opportunity to select a PCMP by contacting HealthColorado, the Department s enrollment broker. 11

12 ACC Members can be attributed to a Primary Care Medical Provider s panel in any of the following ways: New Members may be automatically assigned to a Primary Care Medical Provider upon enrollment because the practice was already identified as the Member s medical home provider, or the Member has a claims history with the practice; The Member calls HealthColorado (Medicaid s enrollment broker) or the Member s RCCO to select the practice as his or her PCMP; The Member signs a PCMP Choice Fax Form and the practice faxes the form to HealthColorado (see Appendix D: Fax Enrollment Form); or A previously unattributed Member has a qualifying visit to the practice, which results in an attribution to the Primary Care Medical Provider via the Department s periodic process of attributing previously unattributed Members to a PCMP via recent claims history, referred to as a reattribution analysis. Once a Member is attributed to a PCMP, via any of the above processes, the PCMP will receive the monthly Per Member Per Month (PMPM) payment from the Department for this Member. Primary Care Medical Providers retain the option to limit their panel to a certain number of Medicaid clients. If the practice sets a limit, the Department will stop assigning new Members to the practice once the practice s panel reaches the limit specified. Primary care medical providers should inform the RCCO with any requests to place a panel limit on the practice. Members can change their PCP at any time by contacting the enrollment broker, HealthColorado. Department PCMP Choice Form Fax Enrollment Form The Department has created a form that allows Primary Care Medical Providers to notify HealthColorado that an unattributed ACC Member requests the practice as the Member s Primary Care Medical Provider. Practices can use this form only when the State s Medicaid eligibility web portal shows the Member is: Enrolled in the Accountable Care Collaborative (ACC) program, and Unattributed to a PCMP. For ACC Members enrolled with RMHP as the RCCO, a Member is unattributed if the State s Medicaid eligibility web portal identifies the Member s PCMP as Rocky Mountain Health Maintenance Org. If an ACC Member already has a PCMP and wishes to change to a different PCMP, the Member must call HealthColorado directly at in the Denver metro area, or outside metro Denver. Primary Care Medical Providers may not use the Fax Enrollment Form for the purpose of switching from one attributed PCMP to another. Primary care practices may only give this form to ACC Members who come in for an appointment. Practices may not mail or this form to ACC Members to recruit them to choose the practice. Once complete: Fax the form to HealthColorado at (303) ; or Mail the form to HealthColorado, 303 E. 17th Ave, Ste. 105, Denver, CO See Appendix D for a copy of the Fax Enrollment Form. 12

13 Getting Paid for the Accountable Care Collaborative Program Payments by Colorado Medicaid for Services Provided Covered services, billing, claims, and payments for Members in the ACC Program are submitted to Colorado Medicaid following Medicaid rules. The Medicaid claims submission process for the ACC program is the same as the current fee-for-service Colorado Medicaid claims submission process. Please consult the Colorado Medicaid Provider Billing Manuals on the Department s website for detailed information regarding claims submissions. Providers that provide Medicaid-covered services to ACC Members are reimbursed based on the Colorado Medicaid fee schedule. Important note: The above statement applies to adult Medicaid members in seven counties in Western Colorado who are enrolled in Medicaid Prime, a Colorado Medicaid Payment Reform Initiative administered by Rocky Mountain Health Plans. The seven counties include: Delta, Garfield, Gunnison, Mesa, Montrose, Pitkin, and Rio Blanco. Claims for services provided to Medicaid members enrolled in this Medicaid payment reform initiative should be submitted to Rocky Mountain Health Plans. Prior Authorization Requests ColoradoPAR Program, administered by APS ColoradoPAR Program is the Utilization Management Program for the Colorado Medical Assistance Program. Following Colorado Medicaid rules, the following PARs must be submitted to the ColoradoPAR Program: Audiology Dental Diagnostic imaging limited to non-emergency Computed Tomography (CT) Scans and Magnetic Resonance Imaging (MRI), and all Positron Emission Tomography (PET) Scans Durable Medical Equipment (DME)/Supply- All (including repairs) EPSDT - Services for clients under 21 years of age Medical/surgical services Organ transplantation Orthodontics Out-of-state elective inpatient admissions Pediatric Long term Home Health Physical and occupational therapy services Private Duty Nursing Reconstructive surgery Second surgical opinions Transportation Vision 13

14 PAR Submission and CareWebQI Portal All PARs and revisions processed by and submitted to the ColoradoPAR Program must be entered through the ColoradoPAR Program web portal, CareWebQI (CWQI). CareWebQI allows for electronic submission of PARs with expedited decisions to PARs, some of them in real time. Webinars are available to assist providers with navigation and use of this web portal. Important note: Internet Explorer (IE 6 or greater) and Safari 6.0 are currently the only supported browsers for CareWebQI. Other browsers will result in errors if used with CareWebQI. The ColoradoPAR Program plans to expand the list of supported browsers in the future. Paper PARs Providers may only submit PARs on paper if an exception is granted by the ColoradoPAR Program. Exceptions may be granted for providers who submit five (5) or less PARs per month. PAR forms are located in the Provider Services Forms section of the Department s website. CO PAR line: or Fax line: Payments to Primary Care Medical Providers Per Member Per Month Rate Table The following list contains information on Per Member Per Month (PMPM) payments to Primary Care Medical Providers for Members enrolled in the Accountable Care Collaborative (ACC) program. EFFECTIVE DATE Effective July 1, 2012 AMOUNT $3.00 Per Member Per Month Up to an additional $1.00 per member per month based on RCCO (Regional Care Collaborative Organization) regionalized performance on the Accountable Care Collaborative Key Performance Indicators (KPIs) (see table below). The KPIs are determined based on quarterly regional fiscal-year-to-date performance. They will be paid out within 120 days from the last date of the quarter for which performance is calculated. 14

15 Incentive Payments MEASUREMENT AREA PERFORMANCE TARGET INCENTIVE PAYMENT METHODOLOGY Emergency Room Visits per 1,000 full time enrollees (FTEs) Hospital Re-admissions per 1,000 FTEs Outpatient Service Utilization per 1,000 FTEs MRI, and CT scans, per 1,000 FTEs Percentage improvement compared to the RCCO s own regional FFS baseline for the fiscal year or most recently available twelve-month period Targets and baselines are developed using historical data. The SDAC establishes a RCCOspecific baseline using actual fiscal year FFS experience from previous year data. Level 1 Target: Utilization below baseline, but less than 5% improvement Level 2 Target: Baseline utilization minus 5% or more Percentage improvement compared to the RCCO s own regional FFS baseline for the fiscal year or most recently available twelve-month period Targets and baselines will be developed using historical data. The SDAC will establish a RCCOspecific baseline using actual fiscal year FFS experience from previous year data. Level 1 Target: Utilization equal to or below baseline but less than 5% improvement Level 2 Target: Baseline utilization minus 5% or more Percentage improvement compared to the RCCO s own regional per full-time enrollee utilization of MRI and CT scans for the fiscal year or most recently available twelve-month period Level 1 Target: Utilization equal to or below baseline but less than 5% improvement Level 2 Target: Baseline utilization minus 5% or more Level 1: 66% of full amount Adults $0.20 PMPM Kids $0.13 PMPM Level 2: 100% of full amount Adults $0.30 PMPM Kids $0.20 PMPM Level 1: 66% of full amount Adults $0.20 PMPM Kids - $0.13 PMPM Level 2: 100% of full amount Adults $0.30 PMPM Kids - $0.20 PMPM Level 1: 66% of full amount Adults $0.20 PMPM Kids - $0.13 PMPM Level 2: 100% of full amount Adults $0.30 PMPM Kids - $0.20 PMPM Percentage of eligible members who Level 1 Target: 60% of all eligible pediatric have received at least one members have received at least one well child well-child check during the year visit during the measurement year. Level 2 Target: 80% of all eligible pediatric members have received at least one well child visit during the measurement year. Level 1 Target: Adults - $0.07 PMPM Kids - $0.26 PMPM Level 2 Target: Adults - $0.10 PMPM Kids - $0.40 PMPM 15

16 Key Performance Indicator Breakout for Incentive Payments Adults Children 30 percent Emergency Department utilization 30 percent hospital readmissions 30 percent high cost imaging 10 percent for well child visits 20 percent Emergency Department utilization 20 percent hospital readmissions 20 percent high cost imaging 40 percent for well child visits Data and Reports Statewide Data Analytics Contractor (SDAC) Overview of the SDAC Portal Structure Landing Page: Here, users can find information about the contractor and accountable care, with links to tools (e.g., for population management) and definitions of key terms (e.g., risk adjustment). There is also a blog where the contractor s clients (including Colorado Medicaid), consultants, and others can post about trends in accountable care and what is working, as well as links to the dashboard (see below) and other resources (e.g., technical documentation). Dashboard: The dashboard is an interface that is customized by user type. It provides data appropriate to the type of user and at the appropriate level. Both RCCOs and PCMPs can see who is attributed to their region or practice and the average risk score of the enrollees attributed to them. RCCOs see data on metrics for the entire population for which they are accountable in their region, while PCMPs see data for the patient population attributed to their practices. Overview of the SDAC Portal Metrics Metrics: RCCO- and PCMP-level performance on specified metrics is determined on the basis of Medicaid claims linked to enrollment data. The claims data are refreshed monthly, but lag behind real-time by 3 to 4 months due to delays in claims submission. Metrics are expressed both on a rolling 12-month and year-to-date basis. Users can drill down to see both budgeted and actual average spending per patient on a risk-adjusted basis. Key Performance Indicators (used to allocate incentive payments for PCMPs and RCCOs): Percent improvement in reduction of 30-day readmissions Percent improvement in reduction of ER visits Percent improvement in reduction of high-cost imaging services Percent improvement in well-child visit occurrence Cost metrics (Medicaid spending per attributed beneficiary): Per member per month spending (can drill down to four types of service) Variance from budgeted spending (per member per month) Potentially preventable events: Spending for preventable events 16

17 Readmissions/1,000/year Admissions/1,000/year Visits/1,000/year Services/1,000/year Prescription drug utilization: Prescriptions/1,000/year Percent of prescriptions that are generic Overview of the SDAC Portal Reports and Tools Practice-Level Data: A key ACC program objective is to encourage practices to focus attention on those with the greatest needs. PCMP practices can download individual-level data in Excel format, with the ability to sort their attributed patients by categories including patient name, diagnosis, risk score, cost, and others. Patient data can also be sorted in other ways, for example, by emergency room users. PCMPs can also stratify patients by five risk categories (defined by the SDAC based on claims data) to better understand their practices, look more closely at utilization and spending by different kinds of patients, and use the results to identify and prioritize individuals for care management. The risk categories are: 1) healthy/non-users; 2) those with a catastrophic event (e.g., malignancies, rare and usually high-cost events); 3) women who are pregnant or recently delivered; 4) those with a moderate to major chronic condition; and 5) those with a minor chronic condition. Users can create tables that list patients in a specified category, along with selected information on that patient (e.g., use, diagnosis, risk score, cost of care based on claims). These lists can then be used for patient-specific follow-up. Patient Profile Tool: A PCMP practice can query the system by patient identification number to find out if the patient is in its panel, or enrolled in Medicaid but not in its panel. The practice can see the claims history associated with the individual patients attributed to them. Care Management Reports: Care managers can access all paid Medicaid claims nearly in real-time (taking into account the lag) to identify particular patients in a PCMP practice (e.g., patients newly discharged from hospital with no follow-up; patients with no office visit in past six months). How to Access the SDAC Web Portal Web portal: Note: You will need a login. Access to the SDAC web portal is governed by a fairly strict access policy to ensure that Medicaid client PHI is distributed only to the appropriate parties. You must be a RCCO, PCMP, or Care Coordinator in the Accountable Care Collaborative to access the SDAC information. Information is secure and only available for the Members these entities are responsible for. To receive access, please complete the SDAC User Access Request Form Appendix E. Below are a few notes about the form: Below Date of Request, near the top of the form, select New User For User Access Requirement, select Billing Provider Role 3 In the RCCO dropdown menu, select RCCO 1: Rocky Mountain Health Plans In the Medicaid Billing ID field, please enter your group Medicaid Billing ID You do not need to fill in anything in the NPI field 17

18 Once you ve completed the form, please return it to Nicole Konkoly, either by to or fax to (303) We will review, give RCCO approval and submit the form to the SDAC for their review and approval. Once the request has been approved by the SDAC, you will receive an directly from the SDAC with your login credentials. Treo Solutions provides Introductory Dashboard Trainings via webinar each month. The objective of these sessions is to provide an opportunity to learn how to navigate the SDAC Dashboard and gain a better understanding of the information that is available for your ACC clients. The trainings are publicized in the monthly SDAC newsletter and we are glad to provide information to you upon request. See Appendix E SDAC User Access Request Form Reports from Rocky Mountain Health Plans Annual Reports Gaps in Care Report Gaps in Care reports are provided to all PCMPs on an annual basis, typically near the end of the calendar year. These reports identify the PCMP s attributed ACC Members with specific preventive care and other guideline driven care needs, using HEDIS technical specifications and State raw claims data. The reports are available in electronic and hard copy format. State claims data is used to identify whether Members have received the following screenings, as applicable: Wellness Visit, Age 2-75 years Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening CVD LDL Screening Diabetes LDL Screening Diabetes HbA1c Screening Diabetes Eye Exam Diabetes Nephropathy Screening Important note: All data on the reports is based on State claims data. Provider offices may have more up-to-date records, and if so, your records should take precedence. Members also receive a letter listing any gaps in care identified. The letter also provides the name and telephone number of the Member s PCMP if the Member is attributed to one. 18

19 Monthly Reports Roster Report / Attribution List The Roster Report is a list of the RCCO Members attributed to your practice as the Member s Primary Care Medical Provider (PCMP) as of the beginning of each month. The report is delivered in a password protected Excel spreadsheet format and includes the following information: RCCO Regional Care Coordination Organization Number PCMP ID Primary Care Medical Practice Identification Number PCMP Name Primary Care Medical Practice Identification Name RCO Begin Date Date that the client was enrolled with the RCCO RCO End Date Date that the client is scheduled to no longer be enrolled with the RCCO PCM Span Indicator of whether client was a regular ACC member (ACC) or Medical Home for Children (HOM) PCM Begin Date Date that the client was enrolled with the PCMP PCM End Date Date that the client is scheduled to no longer be enrolled to the PCMP Client ID Client s Medicaid Identification Number Client First Client s First Name Client Last Client s Last Name Client Address Client s Address Client Phone Client s Telephone Number Client Case No Unique household identifier helps identify clients that live in same household DOB Client s Date Of Birth Elig Category Medicaid program that the client is enrolled to Elig Description Description of the Medicaid program that the client is enrolled to Eligibility Begin Date Date that the client became eligible for most recent Medicaid eligibility category Eligibility End Date Date that the client is scheduled to no longer be eligible for Medicaid Race CD Client s Race Lng Cd Client s Primary Language Sex Client s Gender Client Age Client s Age Adult Indicator if the client is an adult. If client is older than 20 = Y, if client is 20 years or younger = N. Client County Code Client s County Identifier Code RCCO ID Regional Care Coordination Organization Number ACRG3 Aggregated Clinical Risk Group Level 3 ACRG3 Description Aggregated Clinical Risk Group Level 3 Description IEN ID PCP Identification Number / Billing ID IEN Name PCMP Name On Previous Roster Report Indicates whether Member appeared on the previous Roster Report. Yes = Y, No = N. This helps to identify retroactive enrollments and new enrollments. Care Management Analysis Tool (CMAT) Report The Care Management Analysis Tool (CMAT) is a monthly report meant to help PCMPs and Care Coordinators identify and target patients needing care management and care coordination. The report is delivered in a password protected Excel spreadsheet format. 19

20 Care Management Information Risk/Acuity-Based Levels of Care Coordination RMHP has developed a tiered system of care coordination addressing the needs of all Members across the care spectrum, from preventive care needs, disease management, complex care needs and transitions of care. Level 1 Preventive care, wellness care All RCCO Members receive a call to help establish a primary care physician or practice. All RCCO Members receive reminders for annual and preventive care screenings. Level 2 Single, well-managed chronic disease Support for the Member to continue to self-manage their disease process. Level 3a - Moderately well-managed Disease Process (controlled and uncontrolled periods; referrals to specialists not required) More robust support for the Member to self-manage their disease process. This may include community classes, care coordinator phone calls, or consults with ancillary professionals (i.e. a nutritionist) in practice settings. Referrals to specialists are not required. Level 3b Moderately managed Disease Process (controlled and uncontrolled periods; referrals to specialists required) More robust support for Member to self-manage their disease process as above; as well as active engagement with the Member and their providers to coordinate care among all providers. Referrals to specialists are required. Level 4 Complex Outpatient Care Coordination Poorly controlled disease process Typically, Members at this level will have multiple morbidities and have multiple barriers accessing the appropriate care, in the appropriate place and time. Locally-based Care Coordinators will build trust-based patient-centered relationships to facilitate the Member s ability to effectively navigate the health care system and facilitate the numerous providers and care coordinators in contact with the Member to effectively care for the Member. Care Coordinators focus on the immediate needs of the Member, therefore, activities may include: home visits, accompanying the Member to appointments, helping the Member access financial and social programs and other activities as needed. Level 5 Transitions of Care In the course of an acute exacerbation of an illness, a Member might receive care from a PCMP or specialist in an outpatient setting, then transition to a hospital admission before moving on to yet another care team at a skilled nursing facility. Finally, the Member might return home, where he or she would receive care from a Home Health nurse. Each of these shifts from care providers and settings is defined as a care transition and local Care Coordinators will work with the Member to manage these transitions. Care Coordination and Community Care Teams The area covered by RCCO region 1 includes the Western Slope and Larimer County. This is a large geographic region and the population is spread broadly across many communities. RMHP s strategy to ensure effective care coordination is through the development of Community Care Teams (CCTs) across the region that provide direct care coordination support to PCMPs. At the current time, five of these teams have been developed across the region. They are located in Durango, Glenwood Springs, Steamboat Springs, (all three cover multiple counties), and there are two in Larimer County, serving the northern and southern halves of the county. These teams are community-based trans-disciplinary teams that were developed to provide moderately intensive to intensive care coordination to targeted Medicaid patients with complex health conditions. Each team consists of various disciplines 20

21 selected to best help intervene in the needs of the targeted population. This includes social workers (MSW/LCSW), behavioral health specialists, registered nurses, nurse health educators, nurse navigators, promotora, and other mental health specialists. Across communities, the CCTs have a close relationship with the primary care medical practices. Sometimes CCT members are even embedded within practices certain days of the week. Also, most of our teams are closely partnered with their local community mental health center. In some cases, the CMHC staffs members of the teams. Where there are gaps in care coordination services that are not fulfilled by existing care coordinators or care coordination support, RMHP works with the community to most efficiently fill those gaps. RMHP works within the existing systems of care to achieve a more effective and streamlined approach to care and services. RMHP Region 1 Care Coordination by County Light green: current counties served by Community Health Partnership of Northwest CO care team Medium green: counties to be served by Community Health Partnership of Northwest CO care team expansion in 2014 Brown: counties served by Mountain Family Health Centers care team Orange: counties served by Community Care Team of the Southwest Red: county served by North Larimer County Medicaid ACC Care Team (Northern part of county) and the North Colorado Health Alliance (Southern part of county) Yellow: counties served by Rocky Mountain Health Plans care management team 21

22 RMHP ACC Member Dismissal Process RMHP understands that from time to time a PCMP may desire to dismiss a Member from their practice and/or to transfer care and management of a Member to another provider due to cause. (See permissible reasons for dismissal in Exhibit 1, attached). In these cases, the RCCO s responsibility is to assist the Member in finding another PCMP and reporting the dismissal to the Department of Health Care Policy and Financing (HCPF). The RCCO staff is committed to assuring every Member is cared for in the setting that best meets their needs. In cases where Member dismissal appears to be imminent, RMHP Care Management staff will engage the PCMP and Member in education and training to identify ways to support the PCMP/Member relationship. Care Management will contact the Member directly to determine if preserving the PCMP/Member relationship is a possibility. NOTE: If the Member s behavior or misconduct poses an imminent threat to the PCMP, to PCMP staff, to other providers, or to other Members, the PCMP may request an immediate disenrollment after it has provided the Member exhibiting the behavior or misconduct an oral warning. HCPF has defined patient dismissal procedures in your PCMP contract as: The Contractor [PCMP] shall provide one oral warning to any Member exhibiting abusive behavior or intentional misconduct, stating that continuation of the behavior or misconduct will result in a request for disenrollment. If the Member continues the behavior or misconduct after the oral warning, the Contractor shall send a written warning that the continuation of the behavior or misconduct will result in disenrollment from the Contractor s plan. The Contractor shall send a copy of the written warning and a written report of its investigation into the behavior to the Contractor s RCCO, as the Department s delegate, no less than thirty (30) days prior to the disenrollment. Process for Dismissal of a RCCO Member Provide one oral warning to the Member. If misconduct continues, provide a written warning to the Member of intent to dismiss. Fax a copy of the PCMP Request for Dismissal Form (see attachment) and the Member s written notice to Rocky Mountain Health Plans (RMHP) Provider Relations (PR) no less than 30 calendar days prior to the proposed dismissal effective date. PR Fax# RMHP will review the dismissal request and will return a signed Dismissal Form to the PCMP within 7 business days. Upon receipt of signed Dismissal Form from RMHP, the PCMP must provide written notification to the Member. The notice must include the reason for dismissal, end date of care, and contact number for the RCCO Customer Service ( or ). Include a statement that the Member should contact the RCCO for assistance in locating a PCMP. Fax a copy of the final written notification to RMHP Provider Relations. PR Fax# Go to the following link for a flowchart for managing difficult physician-patient relationships: Department-accepted reasons for dismissing an RCCO member: The Member moves out of the PCMP s region (not the Regional Care Collaborative Organization (RCCO)-defined region). The PCMP s practice does not, for moral or religious reasons, cover the service the Member seeks. The Member needs related services to be performed at the same time, not all related services are available within the network, and the Member s PCMP or another provider determines that receiving the services separately would subject the Member to unnecessary risk. Other reasons, including but not limited to, lack of access to services covered under the Contract or lack of access to providers experienced in dealing with the Member s health care needs. Any of the following: o Member behavior that is disruptive or abusive to the extent that the PCMP s ability to furnish services to either the Member or other Members is impaired. o A documented, ongoing pattern of failure on the part of the Member to keep scheduled appointments or meet any other Member responsibilities. o Member behavior that poses a physical threat to the PCMP, to the PCMP s staff, or to other Members. 22

23 NOTE: If the Member s behavior or misconduct poses an imminent threat to the PCMP, to other staff of the PCMP, to other providers or to other Members, the PCMP may request an expedited disenrollment after it has provided the Member exhibiting the behavior or misconduct an oral warning. A Member cannot be dismissed due to: Adverse changes in the Member s health status. Changes in the Member s utilization of medical services. The Member s diminished mental capacity. Any behavior of the Member resulting from the Member s special needs, unless those behaviors seriously impair the PCMP s ability to furnish services to that Member or other Members. See Appendix F for PCMP Request for Dismissal Form 23

24 Other Helpful Information More questions? See Appendix A for contact information about the ACC Program Portals to Verify Eligibility How do we know if someone is enrolled in the ACC? Enrollment verification is available by querying Colorado s Medicaid provider portal. RMHP also maintains enrollment information on its RMHP provider portal for contracted providers. RMHP sends a Member ID card to ACC Members to help providers differentiate ACC Members from Members of other RMHP plans. Enrollment should still be verified using one of the portals above. See sample ID cards below. Sample Screenshots of the State s Medicaid provider portal Medicaid ACC / RCCO Member Unattributed to a PCMP Note for Unattributed to a PCMP - Rocky Mountain Health Maintenance Organization, as RCCO, appears in the PCMP field ACCOUNTABLE CARE COLLABORATIVE PROGRAM (ACC) ACC ENROLLMENT: UPDATED: 2/14/2014 Regional Care Collaborative Organization Number: Regional Care Collaborative Organization Name: Rocky Mountain Health Maintenance Organization, Inc. Phone: Primary Care Medical Provider Name: Rocky Mountain Health Maintenance Organization Phone: Address: Primary Care Medical Provider 2775 CROSSROADS BLVD Address: GRAND JUNCTION CO Primary Care Practitioner Name: Phone: MESSAGE: This is an ACC Medicaid Member! This ACC Member has a Regional Care Collaborative Organization (RCCO) that provides care coordination support. All claims will be paid through the usual Medicaid fee-for-service claims system; most specialty services require a Primary Care Medical Provider (PCMP) referral, with the exception of the following: Emergency care EPSDT screening examinations Emergency and non-emergent medical transportation Anesthesiology services Dental and vision services Family planning services Behavioral health services Home and Community-Based Waiver services Obstetrical care * If no Primary Care Medical Provider information is displayed above, please advise the Member to call HealthColorado to select one. Denver Metro area: Outside of Denver: TDD: HealthColorado.org 24

25 Medicaid ACC / RCCO Member Attributed to a PCMP ACCOUNTABLE CARE COLLABORATIVE PROGRAM ACC ENROLLMENT: UPDATED: 2/14/2014 Regional Care Collaborative Number: Organization Regional Care Collaborative Organization Name: Rocky Mountain Health Maintenance Organization, Inc. Phone: Primary Care Medical Provider Name: ABC Health Provider Phone: Primary Care Medical Provider Address: Primary Care Practitioner Name: 123 Main St, USA (ACC) Phone: MESSAGE: This is an ACC Medicaid Member! This ACC Member has a Regional Care Collaborative Organization (RCCO) that provides care coordination support. All claims will be paid through the usual Medicaid fee-for-service claims system; most specialty services require a Primary Care Medical Provider (PCMP) referral, with the exception of the following: Emergency care EPSDT screening examinations Emergency and non-emergent medical transportation Anesthesiology services Dental and vision services Family planning services Behavioral health services Home and Community-Based Waiver services Obstetrical care * If no Primary Care Medical Provider information is displayed above, please advise the Member to call HealthColorado to select one. Denver Metro area: Outside of Denver: TDD: HealthColorado.org 25

26 Medicaid ACC Member ID Cards RMHP mails Medicaid Accountable Care Collaborative (ACC)/RCCO member ID cards to new RMHP ACC program members. These ID cards will help providers identify individuals who are enrolled in the Medicaid ACC program. The Member ID card shows MEDICAID ACC at the top of the card. The Group ID at the bottom of the card indicates RCCOCAID. At this time, if the Member has a PCP selected and listed in RMHP or the State s system, the PCP s information will NOT print on the card. At a future date, the PCP name will be listed on the ACC Program ID card. If the Member has not selected a PCP and the State has not attributed a PCP, the following statement will be printed on the ID Card: Pick PCP: , prompting the member to call our RMHP Customer Service number for assistance in selecting a PCP. The Member can select a PCP with the assistance of our Customer Service staff, however, the Member must call HealthColorado (Colorado Medicaid s enrollment broker) at for his or her selection to be officially designated in the State systems. The Member must notify the Enrollment Broker of their selection. Eligibility should still be verified using one of the following: Querying Colorado s Medicaid provider portal. Querying RMHP s provider portal 26