HMSA New Provider Orientation

HMSA Provider Services Training

May 2017

Agenda

HMSA New Provider Orientation Four Modules Welcome to HMSA (General Orientation) Tools and Resources (Provider Portal, HHIN, Cozeva, etc.) Claims Filing (Requirements, Eligibility, Deadlines, Payment,

etc.) Programs (Payment Transformation, Pay For Quality, QUEST

Integration, etc.)

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Module I – Welcome to HMSA!

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HMSA – “who we are”

How HMSA supports Providers

Provider Services Specialized Teams

About HMSA

Nonprofit, member-focused association founded in 1938, led by a 27-member volunteer board of directors Member of the Blue Cross and Blue Shield Association; delivers

health plans that are accredited by the National Committee for Quality Assurance (NCQA) HMSA’s goal is to break even; we collect just enough premiums to

pay for our member’s health care and our expenses HMSA Foundation – Awarded $1.22 million to 32 organizations

statewide that worked to improve the well-being of communities. Source: 2016 HMSA Annual Report

HMSA Today – Sustainability

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Access and Affordability

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Providers and HMSA

Providers can work with HMSA by: Encouraging patients to make healthy lifestyle choices and

maintain good health Providing cost-effective and quality care – the right care at

the right time in the right setting Managing health care services to keep health care

affordable Informing us early about your data changes (practice

locations, tax ID and payment address) to ensure correct payment of your claims

How HMSA Supports Providers

HMSA has more than 720,000 members in its health plans. Participating providers have access to this potential patient base by contracting with all of HMSA’s plans HMSA Physician Advisory Committees help to develop

policies, set pharmacy guidelines, improve chronic conditions and health & well-being HMSA Physician Advisory Committees consist of

practicing physicians who volunteer their time and expertise

Source: 2016 HMSA Annual Report

How HMSA Supports Providers

HMSA has full-time medical directors responsible for developing medical policies, ensuring claims meet medical review criteria, and directing health services programs

Physician leadership at HMSA: Health Services Division Mark Mugiishi, MD, Executive Vice President, Chief

Health Officer Marc Rosen, MD, Vice President – Medical Management

& Quality Management

How HMSA Supports Providers

HMSA assists providers in conducting their business operations: Direct payment to participating providers Electronic claims filing Electronic Fund Transfer HHIN – Internet tool to verify member eligibility and

benefits, check claims status, ICD-10 Code Translator, prior authorization (via iExchange) and claim submissions Web-based Provider Portal for medical policies and

administrative information that providers need at www.hmsa.com/portal/provider (Provider Handbook)

How HMSA Supports Providers

HMSA supports providers through excellent and friendly provider phone servicing staff: Customer Relations for routine questions, claims status and

benefits. Call 948-6330 on Oahu; 1 (800) 790-4672 from the Neighbor Islands QUEST Integration Provider Service. Call 948-6486 on Oahu;

1 (800) 440-0640 from the Neighbor Islands BlueCard Tele-Service. Call 948-6280 on Oahu; 1 (800) 648-

3190 from the Neighbor Islands Provider Data Administration Call 952-7847 on Oahu; 1

(800) 603-4672 ext. 7847 toll-free on the Neighbor Islands

How HMSA Supports Providers

Provider Data Administration Updates provider data for HMSA’s databases Assist as you to complete your provider registration materials Answer questions about undergoing credentialing, getting set up in

HMSA’s system, and obtaining a provider number

Provider Service Training & Communication Introduces new providers to HMSA and Provider Services Delivers physician-focused training workshops Written and electronic communications Familiarize you with HMSA’s program initiatives, such as HMSA’s Pay

For Quality & Payment Transformation programs

How HMSA Supports Providers

Contracting & Facility Relations Works with providers regarding contract language and terms Facility contracting and managing facility relationships

Provider Service Field Associates Works with providers on claims issues not resolved through Customer

Relations Assists with reimbursement issues, payment and medical policy

coordination Works with providers with standard contracting

Module 2 – HMSA Tools & Resources

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Provider Portal (Newsletters, Training modules, etc.) Electronic Support – HHIN (Eligibility, Claims Status, etc.); HMSA Online Care (Tele-Health) Engagement – Cozeva, Sharecare

Preauthorization – iExchange, NIA, eviCore, CVS Novologix

www.hmsa.com/providers New!

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HMSA Provider Portal New!

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Provider E-Library - HMSA Medical Policies

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HHIN Hawaii Healthcare Information Network HMSA’s website for participating providers to access member plan and benefit information 24/7. Some of the transactions available on HHIN include: Eligibility Verification Plan Benefits Claim Status Report to Provider Preauthorization requests through iExchange Fee Schedules Claim submission using Direct Data Entry ICD-10 Translator

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HHIN Contacts

To Request HHIN Access or Training HHIN Outreach Phone: (808) 948-6255 Email: ETSOutreach@hmsa.com

For HHIN support (password reset, technical problems) HHIN Help Desk Phone: 948-6446 on Oahu or 1 (800) 760-4672 toll free

for Neighbor Islands Email: hhinhelpdesk@hmsa.com

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In 2009, HMSA partnered with American Well and deployed the first consumer centric telehealth system in the country.

• Is an innovative, web-based system available to anyone in Hawaii that brings real-time healthcare services online

• Extends the reach of the existing healthcare infrastructure by connecting patients with healthcare providers through secure videoconferencing and web chat 24/7, 365 days a year.

• Conversations are confidential and secure; just like an office visit. Data encrypted and fully HIPAA and DoD compliant

HMSA’s Online Care ®

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HMSA’s Online Care ®

HMSA’s Online Care allows doctors and health care professionals the opportunity to expand their services outside the traditional practice structure without requiring additional support staff or resources.

Secure and confidential. The patient history, records and financial information are kept secure.

E-Prescribing. Send prescriptions electronically to your patient’s pharmacy.

Integrated claims. No copayments to collect or additional claims to file.

Direct Reimbursement. Payments are paid and deposited weekly into your groups bank account. Telehealth Now. A new and easy way to schedule and initiate Online Care visits with your patients.

HMSA’s Online Care ®

Benefits for Providers

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HMSA’s Online Care allows doctors and health care professionals the opportunityto expand their services outside the traditional practice structure without requiring additional support staff or resources.

HMSA’s Online Care ®

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Need more information? Go to: hocdochelp@hmsa.com Call HMSA’s Online Care at 1-866-939-6013 to get started

What is COZEVA?

Cozeva is a new tool to help doctors maximize efficiency and improve quality. Cozeva is a unified communication system that will allow doctors to track patient care for key quality measures, generate quality profiles to evaluate their own performance, and communicate securely with their patients and other medical professionals.

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COZEVA Personal Edition For HMSA Members

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• Local events • Local resources

• Family • Friends

• iPhone/Android •Web/Email •Text/IVR •US Mail

•PCP • Specialist •Ecosystem

Engagement

Secured Communications across 4

channels

Cozeva Community Cozeva Circles

COZEVA Practice Edition For Physicians

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•Allows non-claim data

•Appointment reminders

•Patient surveys • Intake Forms

•Payer specific •National

Clinical metrics •Performance

Tracking

•Purpose driven •Personalized •Actionable •Timely

Engagement Real-Time

Metrics Engine

Supplemental Data

Automate Administrativ

e Tasks

Quality Performance Management

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Sharecare RealAge Assessment New! Commercial members 18 and older who complete

Sharecare RealAge assessment at least once during the measurement year. Gauges how fast you’re aging based on lifestyle and medical history. Replaces Well-Being 5 More information to be provided. Explore at

https://www.sharecare.com/static/realage-test

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www.hmsa.com/search/providers

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Sharecare Find a Doctor Tool New!

Enhanced provider profile Comprehensive platform to

promote your practice and improve patient outcomes Ability to add Video/Q&A

content

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iExchange, NIA, eviCore, Novologix, Beacon Health

Prior Authorization Resources

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HHIN Single Sign On (SSO)

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Also known as evicore

<Provider’s NPI and name here>

iExchange (HMSA Medical)

Online preauthorization available 24/7 except for the 1st Sunday of the month from 10pm to 2 am HST and the 3rd Sunday of the month from 6am-10am HST. Functions include searches by member, treatment, and

provider Secure, web-based, automated preauthorization tool Supports submission and online approval of medical services

(i.e. Speech Therapy); Coming soon! Applied Behavior Analysis Accessible via HHIN or Cozeva

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How to access iExchange

Access iExchange through HHIN or Cozeva: Request access to HHIN

Phone: 1 (808) 948-6255 Email: ETSOutreach@hmsa.com

Request access to Cozeva

Phone: 1 (888) 448-5879 toll-free, Monday through Friday, 8 am – 5 pm Hawaii time

Required Internet Browsers: Mozilla Firefox, Safari, or Internet

Explorer (6.0-9.0) 7/7/2017 34

National Imaging Associates (NIA) – Preauthorization

HMSA’s partner in radiology management, with over 20 years of experience

Certified by NCQA for utilization management

HMSA retains claims adjudication functions & oversight of NIA’s utilization management program

Emergency room, observation and inpatient procedures do not require precertification from NIA.

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Preauthorization - NIA Management of:

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• MRI/MRA/MRS • CT/CTA • PET • CCTA • Myocardial perfusion imaging • MUGA

• Stress Echocardiography • Spinal Interventional Pain Management

• Implantable Cadioverter Defibrillator

• Cardiac Resynchronization Therapy Pacemaker

• Pacemaker • Cardiac Catherization • Lumbar Spine Surgery

NIA Preauthorization – additional information Clinically Urgent Cases Cases that cannot be postponed for 24 hours due to severe

health risks for the patient Call 1 (866) 842-1776 Automatically Approved

Radiology Management Quick Reference Guide https://hmsa.com/portal/provider/zav_pel.aa.nia.100.htm Requesting Preauthorization through NIA: https://www.radmd.com/RadMD/Common/Login.aspx or call NIA at 1 (866) 306-9729

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eviCore – Preauthorization of Rehabilitation Services HMSA covers… Medically necessary visits only Medical necessity is determined by ongoing assessment of the

patient Not “what the doctor ordered” but what the patient needs to

return to basic function

Note: The provider is responsible for communicating with the referring physician

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Rehabilitation Care – additional information The following link contains information on how providers register with eviCore (formerly Landmark) https://uni.lmhealthcare.com/lhapps/Login/tabid/73/Default.aspx?returnurl=%2fLHApps%2f Landmark FAQs, and forms: http://www.hmsa.com/portal/provider/zav_pel.rt.lan.500.htm

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CVS – Novologix Preauthorization of Medical Specialty Drugs CVS is responsible for: Managing the pre-certification of all Medical Specialty

Drugs Administer HMSA Medical Policies for specific drugs Apply clinical and claim edits

Medical Specialty Drugs must be filled by a HMSA Participating Specialty Drug Pharmacy

Using contracted Specialty Pharmacies can help to: Coordinate care with patient, physician and pharmacy Monitor/manage therapy Monitor medication compliance Prevent waste

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Medical Specialty Drugs - Definition A Specialty Drug is a drug that is typically high cost and has

one or more of the following characteristics: Specialized patient training on the administration of the drug

(including supplies and devices needed for administration) is required Coordination of care is required prior to drug therapy initiation and/or

during therapy Unique patient compliance and safety monitoring requirements Unique requirements for handling, shipping and storage Restricted access or limited distribution

Medical Specialty Drugs are injectable/infusible specialty drugs Pharmacy Specialty Drugs are oral/inhaled specialty drugs

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Novologix - Medical Specialty Drug Program

New online Prior Authorization (PA) tool, NovoLogix, is accessed through HHIN or Cozeva

Requesting provider may view the status of their requests in NovoLogix

New HMSA/CVS Caremark drug-specific policies have been developed: http://info.caremark.com/hmsapolicies

A NovoLogix training video is available at: https://www.youtube.com/watch?v=SsHgdfiStx0&feature=youtu.be

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Beacon Health Options

HMSA’s partner in reviewing preauthorization requests for medical necessity: Mental health/Substance Use acute inpatient stays longer

than 5 days Mental health/Substance Use Residential Treatment

Center admission and continued stays Methadone treatment for QUEST Integration members Intensive Outpatient and Partial Hospitalization services by

non-participating providers

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Beacon Health Options – Additional Information HMSA provider portal

https://hmsa.com/portal/provider/zav_pel.aa.BEA.100.htm Preauthorization form

https://hmsa.com/portal/provider/Behavioral_Health_UM_Prior_Authorization_Request_Form.pdf

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Plan Phone Fax Hours M-F

Commercial 1-(855) 856-0578 1 (808) 695-7799 8am-4pm

QUEST Integration

Oahu (808) 695-7700

Oahu (808) 695-7790

7:30am -4:30pm

Neighbor Islands 1(855) 856-0578

Neighbor Islands 1(855)539-5880

7:30am- 4:30pm

Module 3 – HMSA Claims Filing

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Check Eligibility

Interactive Claims Filing Tool

Claims Filing Requirements

Claims Filing “Tips for Success”

Step-by-Step Instruction – Eligibility

Be sure to check eligibility at every encounter to ensure your patient’s health insurance is current. • HHIN: https://hhin.hmsa.com/

• Membership Connection 948-6244 (Oahu) 1 (800) 552-8507 (Neighbor Islands)

• QUEST Integration Provider

Service 948-6486 (Oahu) 1 (800) 440-0640 (Neighbor Islands)

Health Insurance Claim Form 1500 (02-12) Step-by-Step

TIP: This easy interactive training tool walks you through the claim form step-by-step Note: use Internet Explorer for a better experience

http://www.hmsa.com/PORTAL/PROVIDER/cms1500_interactive_02_12.pdf

In the Provider Portal, under “Forms” of the home page, click “General forms” scroll and look for link to CMS 1500 interactive training tool for hard-copy claims.

Health Insurance Claim Form 1500 (02-12) Step-by-Step Claims Filing Requirements • Current original claim form. Photocopies may not be used for original

claim submissions. • Double check member numbers and all procedure codes and

diagnosis codes • File claims promptly – HMSA will accept claims 1 year from the date

of service for processing • Choose the correct HMSA 10-digit provider number for the practice

location to AVOID delays in claims processing and payments • Don’t use highlighters or “white out” on the claim form. This

negatively affects the claim scanning process

Health Insurance Claim Form 1500 (02-12) Step-by-Step Tips to Prevent Common Errors Proofreading is essential – transpositions are common

Check to be sure all required fields are complete

Forms must be signed by the provider or an Authorized Agent

Type or computer generate using a minimum size 10 font. Don’t try to “squeeze” more information in by using smaller fonts.

Use dark ink. Replace printer cartridges or toner when the type begins to fade.

For a list of form vendors see https://hmsa.com/portal/provider/zav_pel.aa.cms.600.htm

Electronic Transactions

EDI (Electronic Data Interchange). A communication system that allows the electronic exchange of data between business partners. HMSA supports the following EDI transactions: Electronic Claims Submission (837) Electronic Eligibility Verification (270, 271) Electronic Claim status (276) Electronic Remittance Advice (835) Electronic Report to Provider (eRTP) Electronic Funds Transfer (EFT)

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How to start filing claims electronically

Call the EDI Help Desk Phone: 948-6355 on Oahu or 1 (800) 377-4672 toll-free for

Neighbor Islands Fax: All islands – 1 (808) 948-6008

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Module 4 – HMSA Programs

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BlueCard Program

QUEST Integration

Akamai Advantage/DSNP/MOC

Transforming Physician Compensation

HMSA Quality Programs HMSA Care Models

BlueCard Program

BlueCard Program

A National Program that enables members of one Blue Plan to obtain healthcare benefits while traveling/living in another Blue Plan service area Providers can submit claims for patients from other Blue Plans,

domestic & international to HMSA (local Blue Plan) HMSA is sole contact for claims payment, adjustments and

Issue resolution Products offered (but not limited to) include:

PPO (Preferred Provider Organization) HMO (Health Maintenance Organization) Medicare Advantage

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BlueCard Program – How to identify members The three-character alpha prefix is key to identifying a Blue

Plan or National Account to which the member belongs to Make copies of front and back of membership cards Blue Card ID cards have a suitcase logo Example of card:

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BlueCard Program – Provider Benefits “Single Point of Contact” – Providers can contact HMSA for

claims inquiries, claims status, etc. Eligibility – Providers can submit an electronic eligibility inquiry

or call 1-800-676-BLUE (2583) Claims Filing Instructions – File claims to HMSA the same way

claims are filed for HMSA members. This includes Medicare-related claims Prior Authorizations – Providers may:

Submit an electronic inquiry to HMSA via HHIN “Pre-Service Review” www.hmsa.com/providers; click on “Out of Area Policies” Call 1-800-676-BLUE (2583)

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BlueCard Claims Flow

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HMSA QUEST Integration Plan

QUEST Integration Members

HMSA’s QUEST Integration members

Non-ABD (Doesn't include

Aged, Blind or members with

disabilities)

ABD (Aged, Blind or members with

disabilities)

ABD and LTSS (Aged, Blind or members with disabilities who have additional LTSS benefits)

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Verifying Member Eligibility

Check membership ID card at each visit or encounter Access HMSA’s Hawaii Healthcare Information Network (HHIN) Available 24 hours, 7 days/week Free access and support

Call QUEST Integration Provider Service 948-6486 (Oahu) 1 (800) 440-0640 (Neighbor Islands) Monday – Friday, 7:45 a.m. to 4:30 p.m.

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Verifying Member Eligibility

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Service Coordination

A person-centered service delivery system Ensures the needs of those with special health care needs and

those receiving long term services and supports are met Service coordinators assist in coordinating services with other

agencies, programs, and community services Call QUEST Integration Provider Service for Service

Coordination referral: 948-6486 (Oahu) 1 (800) 440-0640 (toll free)

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Service Coordination Who is eligible? Children with Special Health Care Needs (SHCN) Adults with SHCN Members at risk Institutionalized members Members receiving home and community-based services Members opting for self-direction

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Member Billings No balance billing of QUEST Integration members Providers accept QUEST Integration payments as payments in

full Members can be billed for Non-covered services or upgraded services (member-

signed Financial Agreement Statement required) Services rendered before/after eligibility Primary insurance payments sent to the member or plan

subscriber by the other insurance Cost shares

No-show fees cannot be charged to QUEST Integration members.

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Administrative Information/Resources Provider Communications HMSA website: hmsa.com Provider Portal QUEST Integration Provider Handbook HMSA HealthPro News Other HMSA communications

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Excluded Providers QUEST Integration and Akamai Advantage

Plans

Excluded Providers What is an Excluded Provider?

Individual or Entity who is not allowed to receive reimbursement for providing Medicare or Medicaid services

Provider Responsibilities

Search Excluded Provider lists routinely (i.e., monthly) to confirm that employees or contractors are not on any list AND

Search Excluded Provider lists prior to hiring staff to confirm that potential employees or contractors are not on any list

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Federal Excluded Provider Lists (QUEST Integration & Akamai Advantage)

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• General Services Administration Excluded Parties List System (EPLS)

• https://www.sam.gov/index.html/#1#1#1

• List of Excluded Individuals and Entities (LEIE), a health care specific exclusion list

• https://exclusions.oig.hhs.gov/

State Excluded Provider Lists (QUEST Integration only)

Government contracting exclusion list http://spo.hawaii.gov/for-state-county-

personnel/manual/debarment/

DHS Med-QUEST Division’s exclusion list http://www.med-

quest.us/providers/ProviderExclusion_ReinstatementList.html

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HMSA Akamai Advantage Plan and Dual Care/Model of Care

Why choose Akamai Advantage?

Large statewide provider network Comprehensive benefits – all Original Medicare

benefits, and more Financial protection – Maximum Out-of-Pocket limit Predictable costs

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Akamai Advantage plans

HMSA Akamai Advantage has options available on every island All options include Part D drug coverage

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Oahu plans Neighbor Island plans

Complete (706) Standard (708)

Complete Plus (707) Standard Plus (709)

Akamai Advantage Dual Care Plan Dual Care Plan Must be eligible for Medicare and Medicaid May be Qualified Medicare Beneficiary (QMB) Only or

(QMB) Plus dual eligibility status May have HMSA Akamai and HMSA QUEST Integration May have HMSA Akamai and QUEST Integration with

another health plan

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Akamai Advantage Dual Care Membership Card

• Plan Name appears at the top right corner of the front of the card • No member premium (after Low Income Subsidy)

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Strengthen Care Management Support through Model of Care Improve access to essential services such as medical &

behavioral health care and social services Improve access to: Affordable care Preventive Health Services

Improve coordination of care through assignment of an HMSA Care Manager Improve seamless transitions of care across health care

settings, providers, and health services Ensure appropriate use of services Improve health outcomes

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MEMBER

Health Risk Assessment

(HRA)

Individualized Care Plan

(ICP)

Interdisciplinary Care Team

(ICT)

Model of Care

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Akamai Advantage Dual Care member is at the center

Most Vulnerable

Somewhat Vulnerable

Least Vulnerable

Model of Care Support for your vulnerable patients

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Determined by HRAs and clinical

judgment

Examples of criteria for “most vulnerable” • 5 or more chronic comorbid

conditions (diabetes, congestive heart failure, hypertension, etc.)

• Terminal condition • 5 or more ER visits within

the past 6 months • Severe dementia

Health Risk Assessment and Care Plan

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Health Risk Assessment (HRA)*

1. Conducted by HMSA Care Manager

2. Frequency: a. Initial within 90 days b. Reassess at least annually c. Health events

3. Used to Risk Stratify 4. Methodology

a. In-person b. Telephonic c. Mail

5. Used to formulate ICP

Individualized Care Plan (ICP)*

1. Based on HRA results 2. Aerial algorithms and

clinical judgment 3. Developed with input

from ICT 4. Modified as needed 5. Communicated to

member, providers and ICT

6. Shared during care transitions

* Must be evidence-based

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Transforming Physician Compensation

PCP Engagement and Performance

Reaching Māhie 2020 Requires Transformation

Our current

healthcare system:

A fragmented, increasingly

unsustainable system that both patients and providers have

difficulty navigating.

Māhie 2020: A sustainable community

health system that advances the health and well-being of Hawaii

Consumers

Providers

Employers

Communities

Government

HMSA

Payment Transformation Will Address Key Goals In Pursuit of Māhie 2020 - Maximize Value to Members, Providers, and Employers

• Improve member experience and quality of care better

health and well-being

• Doctors will be able to practice medicine the way they think it should be practiced

• Achieve Triple Aim: Access, Cost, and Quality (Health and well-being) build a new value-based sustainable model of care

A Transformed Primary Care Payment Model “The Journey Begins…”

Patient

Primary Care as the Foundation

Specialists Facilities

Key Concepts in Payment Transformation

HMSA wants to keep PCPs close to whole financially (on PMPM basis, using three-year FFS and member months data) during the transition period Move from volume-based to value-based reimbursement Alignment with CMS initiatives (i.e. MACRA, CPC+, MSSP) Help physicians start to manage whole patient populations

and promote health and wellness

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PCP Services Counted and Included in Global Base PMPM Payment

All services rendered by the PCP including: Office visits, hospital visits, newborn care Procedures Labs, EKGs and TB and other tests billed by

PCP. Injectable drugs administered by PCP. Services to patients when their PCP was on vacation, or other

coverage situations Vaccine administration Immunizations will be paid FFS

HMSA counts three years of claims data by service date, with three months of run out

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Services Not Included in Global Payment PMPM Calculation

These services are NOT included in global payment calculation because these claims will still be paid FFS: All immunizations All claims for BCBSA Federal Employee Plan (FEP)

members All claims for other Blue Cross and Blue Shield Association

members

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Primary Care Requirements

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• Must be a participating provider in all HMSA lines of business • Be a credentialed PCP in one of the following: General

Practice, Internal Medicine, Family Medicine, Pediatrician, Naturopathic Physician, APRN, PA under supervision of a PT program-eligible physician

• Program Eligibility – Must contract with only one Physician Organization

• View training videos and learn about HMSA Payment Transformation at https://hmsa.com/portal/provider/edu_index.htm

HMSA Quality Programs

Investment in Quality

Pay for Quality programs – Focus on outcomes Hospitals Specialists (coming soon!)

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Advanced Hospital Care (HMSA’s Hospital Quality Program) Supports the delivery of health care that is high in quality, cost effective,

and reliable.

Promotes corporate culture focused on quality and collaboration among hospitals.

Provides for transparency and sharing of data among the hospitals.

Aligns with national standards and guidelines.

Non-negotiated quality program based on unique hospital attributes (e.g., perinatal, NSQIP, minimum denominators)

No fixed fee increases (fee increases based on performance in quality measures)

Quality payments made as a bonus linked to volume (added to DRG, ASC, ER payments, and not integrated into fee schedule)

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Performance (Quality) Requirements & Compensation

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• Must be a participating primary care physician/provider. • Providers are one of the following: General Practice, Internal Medicine,

Family Medicine, Pediatrician, APRN, PA under supervision of a PCMH-eligible physician

• Program Eligibility – Physician Organization participation for Commercial, QUEST Integration and HMSA Akamai Advantage

• Executed Payment Transformation Program amendment to participating physician/provider agreement for Commercial, QUEST Integration and Akamai Advantage

• Scoring Threshold • Achieve minimum threshold = 40% of max payment potential for

the measure • Achieve target threshold = 100% of max payment potential for the

measure

Performance (Quality) Measures

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• HMSA’s Primary Care Performance (Quality) Program is included in HMSA’s Payment Transformation Guide located at: HHIN: https://hhin.hmsa.com/

• Contains information on programs and measures for Commercial, Akamai Advantage, and QUEST Integration

• Details for each quality measure are available in Appendix D

HMSA Care Model

Mahalo!

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Living healthy and enjoying life to the fullest. That’s what we’re striving for.