Enrollee Health Assessment Program Implementation Guide and Best Practices

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1 Enrllee Health Assessment Prgram Implementatin Guide and Best Practices March ( )

2 This guide will help yu answer these questins: What is the Enrllee Health Assessment (EHA) prgram and the Annual Health Review (AHR) visit? Hw d we receive EHA prgram infrmatin frm Premera? What d we need t knw t schedule patients? What d we need t d during an Annual Health Review visit? What d we need t knw abut submitting claims and dcumentatin? 2

3 Use this guide t help plan implementatin f the EHA prgram in yur clinic This guide is intended t help yu think thrugh rles, tasks, infrmatin, and prcesses needed t make the implementatin f the EHA prgram successful Additinal resurces, including best practices frm ther clinics, are at the end f this deck 3

4 Premera s Enrllee Health Assessment Prgram The Enrllee Health Assessment (EHA) Prgram gal is t imprve member health by helping prviders identify and manage their patients chrnic cnditins thrugh prcesses that: Imprve identificatin f high-risk patients wh may qualify fr Premera utreach f care management services Encurage prviders t cmpletely assess, dcument, and cde the diagnses, severity, testing, and treatment plans fr their patients chrnic cnditins Ensure prviders get credit fr the wrk they are already ding, but may nt be capturing thrugh apprpriate dcumentatin, cding, and claims submissin 4

5 The Annual Health Review The EHA prgram accmplishes its gal f imprving patient health thrugh the Annual Health Review (AHR) visit The Annual Health Review (AHR) visit shuld be cnducted nce a calendar year by EHA-cntracted prviders Premera will send a list quarterly f patients wh qualify t be in the EHA prgram and shuld receive an AHR visit 5

6 Annual Health Review Prcess Befre AHR Visit During AHR Visit After AHR Visit 6

7 What happens befre the AHR visit? Premera mailings Premera Sends a Member Outreach Reprt quarterly Clinic Reviews Member Outreach Reprt Ntifies Premera if any members n Member Outreach Reprt are nt their patients Begins scheduling patients fr the AHR visit Premera Sends clinics the Health Histry Summaries fr each eligible patient tw weeks after the Member Outreach Reprt is sent Clinic Ensures that clinicians have access t Health Histry Summaries prir t the visit t review pssible HEDIS gaps r suspected cnditins 7

8 What happens befre the AHR visit? Patient scheduling The clinic will cntact the patients listed n the Member Outreach Reprt t schedule the Annual Health Review visit Suggested talking pints when scheduling appintments: Yu may have recently received a letter frm Premera encuraging yu t have an Annual Health Review The Annual Health Review is an pprtunity t assess any current health cnditins, ensure that yu re getting the right treatment plan, and find any ptential health prblems early The visit is cvered 100% by yur plan and is nt subject t cpay, deductible, r c-insurance. Keep in mind that if we find any health issues f cncern and rder diagnstic tests, yu may be respnsible fr paying part f the cst f thse tests The scheduler shuld ensure that patient eligibility (insurance cverage is in effect) is cnfirmed prir t the date f service Once scheduling f members is cmplete, the clinic shuld fill in the Member Outreach Reprt and fax back t Premera at

9 Hw are the tasks prir t the AHR visit cmpleted at my clinic? Exercise: Use the table belw as a tl t think thrugh hw the varius tasks wuld be cmpleted at yur clinic Task Team Member Trigger Ntes Review Member Outreach Reprt t validate members are patients. Send feedback t Premera. Actin initiated when mailing received. Cntact patients t schedule AHR visits. Health Histry Summary infrmatin ruted t Clinician. If a patient calls us t schedule, ensure patient is remved frm call list. Call Premera t cnfirm patient is eligible t be seen n DOS. Ensure patient is scheduled in a manner that indicates t the clinician the nature f the visit. (I.e., patient charts are flagged t pp up with suspected cnditins upn pening the patient recrd.) 9

10 What des the clinician d during the AHR visit? 1. Cnfirms r denies suspected cnditins n the Health Histry Summary and dcuments the status f each cnditin in the patient s medical recrd 2. Reviews patient s prescriptin histry and cnfirms all medicatins are current 3. Verifies the HEDIS Care Gaps listed n the Health Histry Summary are apprpriate and addressed 4. Cnducts Annual Health Review cmprehensive evaluatin and management f chrnic cnditins 5. Dcuments and cdes t the highest specificity, ensuring the dcumentatin supprts the cdes reprted Each assessed cnditin shuld have at least ne f the fllwing types f dcumentatin t supprt it: Treatment Assessment Medicate/medicatin Plan Evaluate Referral (TAMPER) This can be as simple as hypthyridism stable n medicatin, refill fr ne year 6. Ensures that signature is legible and includes first name, last name, credentials, and date. If the signature is electrnic, it shuld include the date and time f authenticatin, the clinician s name and credentials, and a statement such as electrnically signed by 10

11 Hw are the tasks during the AHR visit cmpleted at my clinic? Exercise: Use the table belw as a tl t think thrugh hw the varius tasks wuld be cmpleted at yur clinic Task Team Member Trigger Ntes Cnfirm r deny any HHS suspected cnditins in visit dcumentatin Clinician (I.e., clinician given HHS frm by rming MA) Cmplete visit and dcumentatin including diagnses f all chrnic cnditins t highest specificity Clinician Cnfirm eligibility fr nn-eha prgram patients that yu feel wuld benefit frm an EHA visit Clinician (E.g., alert billing ffice t check EHA prgram eligibility fr clinicianidentified patient. Cnduct EHA visit after eligibility is cnfirmed.) 11

12 What happens after the AHR visit? Claim submissin Upn cmpletin f the Annual Health Review, the prvider shuld: Ensure claim has the apprpriate prcedure cde: G0438 Initial visit with the EHA prgram G0439 Subsequent annual visit with the EHA prgram Ensure claim has the apprpriate diagnsis cdes; d nt use preventive cdes If the Annual Health Review was dne in cnjunctin with ther visit types (preventive exam r a visit t evaluate and manage ther acute cnditins) dcumentatin must supprt multiple visit types and a mdifier 25 must be used. Be careful t ensure that: The G0438/9 is pinted t chrnic and cmplex cnditin diagnses The prblem-fcused E&M cde ( ) is pinted t nn-preventive diagnses The preventive exam cde ( ) is pinted t preventive diagnses such as V70.0 r V

13 What happens after the AHR visit? Dcumentatin submissin The clinic shuld send ne f the fllwing frms f dcumentatin that validates the suspected cnditins fund n the Health Histry Summary sheet and any ther cnditins identified during the cmprehensive exam: Cmplete chart ntes Cmpleted Enrllee Health Assessment frm The Health Histry Summary frm can be used as a cver sheet. If nt, all dcumentatin shuld include the fllwing infrmatin: Prvider name, TIN, date f service Member name, date f birth, member ID 13

14 Hw are the tasks after the AHR visit cmpleted at my clinic? Exercise: Use the table belw as a tl t think thrugh hw the varius tasks wuld be cmpleted at yur clinic Task Team Member Trigger Ntes Ensure claim fr DOS (with apprpriate G-cde and diagnses) is sent t Premera (I.e., message is sent t cder that this visit shuld be billed as an AHR visit) Ensure claim is supprted by dcumentatin Ensure chart nte r EHA frm is sent t Premera fr the cmpleted AHR visit Ensure HHS frm is included as a cver sheet with dcumentatin (r that dcumentatin is labelled apprpriately) (I.e., HHS frm ruted by clinician s MA t cder) 14

15 Resurces 15

16 Cntact infrmatin Call ur dedicated prvider line at , ptin 4, r us at fr: Assistance with the EHA prcess Questins regarding member qualificatin Any questins r cncerns related t Cmmercial Risk Adjustment/ EHA Prgram Fax yur chart ntes/frms t:

17 Cnfirming eligibility Cntact ur dedicated prvider line at , ptin 4 t cnfirm that the patient has paid their premium and is eligible t be seen n the date f service T determine prgram eligibility fr patients wh were nt identified by Premera, cntact the abve prvider line t cnfirm that the patient has: Tw r mre chrnic cnditins An individual r small grup metallic plan (brnze, silver, r gld) Paid their premium and is eligible t be seen n the date f service Heritage Plus Essential Silver 3000 DED 17

18 Best practices f EHA prgram implementatin Clinics that successfully implemented EHA shared these tips: Have ne pint persn t receive mailings Schedule the apprpriate amunt f time fr the AHR visit t review all suspected cnditins and develp r revise treatment plans Train staff wh will manage the prcess (frnt desk, scheduler, cder, billers, and clinicians) Have a template fr AHR visit easily available fr clinician Have a drp-dwn chice fr clinicians in EMR If nt EMR, have template laminated and put in every exam rm Have a reminder n the chart r in the EMR fr prvider t knw type f visit Have the Health Histry Summary available fr the clinician t review with the patient during the visit Have cders (nt the prvider) cde the claim and: Ensure the crrect G cde is n the claim Ensure the primary diagnsis cde n the claim is nt fr a wellness visit Have dedicated persn fax chart ntes back t Premera 18

19 Additinal resurces We have tls and resurces t assist yu Yu can find additinal tls, resurces, and infrmatin regarding the Enrllee Health Assessment Prgram n Premera s website. On the prvider hme page lk fr Enrllee Health Assessment What s New: AHR Visit Guide EHA 301 CRA vs. MRA Cmparisn AHR vs. Other Visit Type Cmparisn Existing Resurces: CRA 101 EHA 201 EHA Prgram User Guide Cding Tip Sheet Patient Scheduling Talking Pints 19

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