You re Enrolled in PQSR 2004 May 14, 2004 Dear Doctor: Each year, HMSA asks practitioners to update the information in their Provider Information file to assist in prompt claims processing and payment. Some of this information is used in calculating your score for HMSA s Practitioner Quality and Service Recognition (PQSR) Program. Our records indicate that you are enrolled in PQSR for 2004. Please review the enclosed Provider Basic Information and Provider Location Information printouts. Information is also included for any group in which you practice. If the information is not accurate, please make any corrections directly on the printouts and return them in the enclosed business-reply envelope by June 8, 2004. An instruction form is also enclosed. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. Please complete and return the enclosed Provider Basic Information and Provider Location Information printouts by June 8, 2004. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. Enclosure PS04-041a
Your Provider Information Update and Invitation to PQSR 2004 May 14, 2004 Dear Doctor: Each year, HMSA asks practitioners to update the information in their Provider Information file to assist in prompt claims processing and payment. Please review the enclosed Provider Basic Information and Provider Location Information printouts. Information is also included for any group in which you practice. If the information is not accurate, please make any corrections directly on the printouts and return them in the enclosed business-reply envelope by June 8, 2004. An instruction form is also enclosed. HMSA is also extending a special invitation to qualifying practitioners who have not done so to enroll in HMSA s Practitioner Quality and Service Recognition (PQSR) Program. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. If you wish to enroll in the PQSR Program, please sign and return the INDIVIDUAL Enrollment Form along with the Provider Basic Information and Provider Location Information printouts by June 8. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. Enclosure PS04-041b
Optometrist Information Update and Invitation to Enroll in PQSR 2004 May 14, 2004 Dear Doctor: Each year, HMSA asks practitioners to update the information in their Provider Information file to assist in prompt claims processing and payment. Please review the enclosed Provider Basic Information and Provider Location Information printouts. Information is also included for any group in which you practice. If the information is not accurate, please make any corrections directly on the printouts and return them in the enclosed business-reply envelope by June 8, 2004. An instruction form is also enclosed. This year, optometrists are being included in the HMSA s Practitioner Quality and Service Recognition (PQSR) Program. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. If you wish to enroll in the PQSR Program, in addition to correcting the Provider Basic Information and Provider Location Information printouts, please sign and return the INDIVIDUAL Enrollment Form by June 8. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. If you have additional questions about the PQSR program, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. Enclosure PS04-041c
INSTRUCTIONS Correcting Your Provider Information May 2004 We appreciate your help in ensuring that the information HMSA has about you is complete and accurate. Please review the enclosed Provider Basic Information and Provider Location Information printouts. If any information is incomplete or inaccurate, please make corrections directly on the printouts and return them in the enclosed business-reply envelope by June 8, 2004. Listed below are explanations of the items listed on the printouts. PROVIDER BASIC INFORMATION Items 1-9 include information for all locations. 1. Provider Name Provider s last name, first name and middle initial. 2. Gender Provider s gender. 3. SSN/TIN Number Your Social Security Number (SSN) or Taxpayer Identification Number (TIN) if you are an individual provider. If the federal ID number is wrong, please indicate the new number and submit a copy of the notification letter from the IRS of your TIN. If you are with a group or employed by another provider, use your own SSN or TIN. 4. Mailing Address The location where correspondence should be mailed. 5. Board Certification/Specialty The name of the board granting certification and the specialty in which you are certified. If you have additional specialties or are recently board certified, please provide HMSA with the documents confirming your specialty(ies). 6. UPIN # The Unique Physician Identification Number (UPIN) for ordering or referring issued to you by Medicare. This is a different number than your Medicare provider number listed in item 22. For PQSR Scoring, please include the following information: Items 7-9 are used for the Practitioner Quality and Service Recognition Program. 7. Take Call AND Privileges at Neighbor Island Hospitals as of March 31, 2004 Place an X in the box next to the hospital at which you take call and have active privilege as of March 31, 2004, if applicable. HMSA retains the right to verify this information through credentialing databases and other sources. 8. Please indicate whether you use an electronic prescribing system as of March 31, 2004 If you use Allscripts as of March 31, 2004, place X in the box next to Allscripts. If you use another electronic prescribing system (including electronic medical records systems that have electronic prescribing components for transmitting prescriptions to commercial pharmacies) as of March 31, 2004, place an X in the box next to Other electronic prescribing system and indicate the name of the system. 9. If you have an individual practice, do you want HMSA to donate your Individual PQSR award to Aloha United Way? The checkmark indicates whether or not the award was given to a charitable organization last year. To indicate whether or not you want your award to go to Aloha United Way this year, place an X in the appropriate box. 1 PS04-041d
PROVIDER LOCATION INFORMATION Items 10-27 include information that is distinct for each provider location. You should have a printout for each location. If not, please call your Provider Services Field Representative or Coordinator, or call 948-5190 for assistance in contacting the field staff. If you are no longer at a location, please indicate the date the location was closed. 10. Claim Submission Number The number used when submitting claims to HMSA for services rendered from the indicated location identified. 11. Location Address The physical location address of the practice. 12. Payment Address If you participate with HMSA, this represents where payments are sent. 13. Group Affiliation If you are part of a group or clinic, this identifies the name of the entity. 14. Marketing Specialty Information How HMSA markets you in directories provided to our members. If this specialty is incorrect, indicate one correct specialty on the printout. 15. Appointment Phone Number The number used by members to schedule appointments. This phone number is included in HMSA directories. 16. Contact Phone Number The number used by HMSA to call you for general provider information. 17. E-Mail Address The address where you receive electronic messages. 18. Fax Number The number used to fax information to you. 19. Fax Number Referral Fax numbers used primarily for referrals. 20. Drug Enforcement Administration (DEA) Number Your DEA number, if you prescribe medication. 21. Medicare Par Status Whether or not you participate with Medicare. If the printout lists your status as nonparticipating or is blank, and you now participate with Medicare, please provide us with a copy of your Medicare Part B letter indicating participation. This can facilitate automatic crossover of claims if an HMSA plan is the patient s secondary coverage and Medicare is the primary coverage. 22. Medicare Number Your Medicare provider identification number (not your UPIN#, which appears in item 6). 23. Clinical Laboratory Improvement Amendment (CLIA) Number The number assigned by Medicare if you are doing in-office lab services. 24. Number of office staff The total number of staff (including provider) at each location. 25. Number of staff members who speak languages other than English (including American Sign Language) The number of staff members who speak a foreign language, including American Sign Language, and the availability of interpreter services. Languages Spoken Place an X in the box next to the languages spoken by persons in your office. This will allow us to advise HMSA members who may not speak English. 26. Handicap Accessibility Whether your office is accessible to people with disabilities. 27. Do you expect any changes to the above information in the next 90 days? If so, indicate the change. 2 PS04-041d
INDIVIDUAL Enrollment Form HMSA s Practitioner Quality and Service Recognition Program 2004 Check one box and sign below. Please enroll me in HMSA s Practitioner Quality and Service Recognition Program. I acknowledge that enrollment is voluntary and that the Practitioner Quality and Service Recognition Program award payment is subject to the following conditions: 1. I am a participating provider with HMSA s Preferred Provider Plans and understand the requirement that I be a participating provider during the Practitioner Quality and Service Recognition Program evaluation period. I understand that I must be a participating provider at the time the Practitioner Quality and Service Recognition Program award is made; any exceptions, such as retirement or relocation outside of Hawaii, will be handled on a case-by-case basis. 2. I practice in a specialty that is eligible to participate in HMSA s Practitioner Quality and Service Recognition Program. 3. I have read and understand the Practitioner Quality and Service Recognition Program Guide, and will participate fully in the Program and the quality improvement activities necessary to evaluate my participation. I am aware that I can find information about the PQSR Program on the Hawaii Healthcare Information Network (HHIN) or on the Internet at http://, or, if I don t have HHIN or Internet access, I can request a CD or a printed copy of the PQSR Program Guide by calling an HMSA Provider Teleservice Representative at 948-6330 on Oahu 4. I agree to accept HMSA s determination of the Practitioner Quality and Service Recognition Program score and understand that this score will serve as the basis for any Practitioner Quality and Service Recognition Program award that may be paid to me by HMSA. A procedure has been established to resolve issues raised by practitioners enrolled in the program about their rankings and scores. 5. I understand the Practitioner Quality and Service Recognition Program award is based on a calculated percentage of my HMSA fee-for-service payments under selected HMSA Plans as described in the Practitioner Quality and Service Recognition Program Guide (see item 3). 6. I further understand that any Practitioner Quality and Service Recognition Program award paid to me will be in addition to all other HMSA fee-for-service payments made under HMSA s Preferred Provider Plans. No other plan payments are included in this Quality and Service Recognition Program, such as HMSA s HMO plans, HMSA s Medical Plan for QUEST Members, Senior Plans, point-of-service plans, major medical, drug and vision riders. 7. My participation in the Practitioner Quality and Service Recognition Program will continue in subsequent years, unless I withdraw my participation by notifying HMSA in writing. 8. I must return this form and return corrected information on the Provider Basic Information printout and Provider Location Information printout to HMSA by June 8, 2004 to be eligible for an award in 2004. 9. If I choose to unconditionally decline the award and have HMSA donate it to charity, I will so indicate by marking yes in item 9 of the Provider Basic Information printout. 10. HMSA will make the Practitioner Quality and Service Recognition Program award payment to enrolled practitioners no later than the end of each calendar year. 11. I understand that due to unforeseen circumstances, such as insufficient data, HMSA may not be able to compute my Practitioner Quality and Service Recognition Program score. 12. HMSA reserves the right to discontinue the Practitioner Quality and Service Recognition Program by providing 60 days notice prior to the start of any new calendar year. I do not wish to enroll in HMSA s Practitioner Quality and Service Recognition Program at this time and understand that I will not be eligible for a Practitioner Quality and Service Recognition Program award in 2004. I will notify HMSA in writing if I wish to participate in the program in a subsequent year. Name of practitioner (printed) HMSA provider I.D. number Signature of practitioner Date PS04-041e
Fax this form to (808) 948-6887 or mail it in the enclosed envelope by June 8, 2004. PS04-041e
PQSR 2004 Group Packet May 14, 2004 Dear Group Administrator: The accompanying packets include the forms for updating the contents of the Provider Information files for the practitioners in your group. HMSA annually asks practitioners to review the information to assist in prompt claims processing and payment. This information is also used for HMSA s Practitioner Quality and Service Recognition (PQSR) Program. Please have the practitioners in your group review these forms and make corrections directly on the printout. The forms must be returned by June 8, 2004. An instruction form is provided with the materials. Please note that practitioners in your group who also have a separate practice have received these materials directly. You may want to remind them to return their Provider Basic Information and Provider Location Information printouts by June 8, 2004 so that their information is included in your group s PQSR award calculation. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. Again, please note that the accompanying printouts must be returned to HMSA by June 8, 2004. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your group s participation in PQSR. PS04-041g
PQSR 2004 Group Packet May 25, 2004 Dear Group Administrator: HMSA annually asks practitioners to review the contents of the Provider Information files to assist in prompt claims processing and payment. This information is also used for HMSA s Practitioner Quality and Service Recognition (PQSR) Program. This year, optometrists are being added as a PQSR specialty. Forms for updating the information have been mailed to the practitioners in your group. In addition, we are providing you with copies of the forms sent to your individual practitioners for you to update, if you prefer to do this for them. Corrections can be made directly on the printout. An instruction form is provided. The forms must be returned by June 8, 2004 so that the information is included in your group s PQSR award calculation. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. Again, please note that the accompanying printouts must be returned to HMSA by June 8, 2004. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. PS04-041h1
Your PQSR 2004 Group Enrollment May 14, 2004 Dear Doctor: Each year, HMSA asks practitioners to update the information in their Provider Information file to assist in prompt claims processing and payment. Some of this information is used in calculating your score for HMSA s Practitioner Quality and Service Recognition (PQSR) Program. Our records indicate that you are part of a group that participated in the 2003 PQSR Program, so you are automatically enrolled in PQSR 2004 for that group. Please review the enclosed Provider Basic Information and Provider Location Information printouts. Information is also included for any group in which you practice. If the information is not accurate, please make any corrections directly on the printouts and return them in the enclosed business-reply envelope by June 8, 2004. An instruction form is also enclosed. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims from April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. Please complete and return the enclosed Provider Basic Information and Provider Location Information printouts by June 8, 2004. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. Enclosure PS04-041h
PQSR 2004 Group Packet May 25, 2004 Dear Group Administrator: HMSA annually asks practitioners to review the contents of the Provider Information files to assist in prompt claims processing and payment. This information is also used for HMSA s Practitioner Quality and Service Recognition (PQSR) Program. This year, optometrists are being added as a PQSR specialty. Forms for updating the information have been mailed to the practitioners in your group. Please remind them to return the forms by June 8, 2004 so that the information is included in your group s PQSR award calculation. Corrections can be made directly on the printout. An instruction form was provided with the forms. Begun in 1998, the PQSR Program has distributed more than $32 million to HMSA practitioners in recognition of high-quality, service-oriented and cost-effective healthcare practices. Practitioners who enroll in the PQSR Program can receive an award based on a calculated percentage of selected fee-for-service payments received from HMSA for claims during the period of April 2003 through March 2004. Program participants also receive personalized reports, drawn from HMSA claims data, which provide useful information about their practices. Again, please note that the accompanying printouts must be returned to HMSA by June 8, 2004. If you have questions, please call your Field Representative or Coordinator. For assistance in contacting your Field Representative or Coordinator, please call HMSA s Honolulu office at 948-5190. We look forward to your participation in PQSR. PS04-041h