Anthem Blue Cross and Blue Shield 2014 Quality-In-Sights Cardiology and Obstetrics/Gynecology Quality Incentive Program

Transcription

1 Anthem Blue Cross and Blue Shield 2014 Quality-In-Sights Cardiology and Obstetrics/Gynecology Quality Incentive Program Part of the Anthem Quality-In-Sights suite of innovative, quality recognition and health improvement programs PLNHB5362A Rev. 12/13

2 Anthem Blue Cross and Blue Shield 2014 Quality-In-Sights Cardiology and Obstetrics/Gynecology Quality Incentive Program Anthem Blue Cross and Blue Shield (Anthem) is pleased to announce the 2014 Anthem Quality-In-Sights (AQI) Cardiology and Obstetrics/Gynecology Quality Incentive Program for eligible participating cardiology and obstetrics/gynecology physicians. This program rewards performance for eligible participating physicians with the primary specialty of cardiology and obstetrics/gynecology throughout the Northeast Region (Connecticut, Maine and New Hampshire) based on nationally endorsed industry standard measures of quality as well as technology adoption, applicable external recognitions*, and resource measures aimed at improving quality and patient safety. *Please note: There are no external recognitions for obstetrics/gynecology physicians. Instead, Anthem will conduct evaluation of paid claims data using HEDIS measures. The 2014 AQI Cardiology and Obstetrics/Gynecology Quality Incentive Program is designed to help address some of the most pervasive and costly health concerns facing our nation. AQI is redefining the relationship that health care physicians traditionally have had with insurers by creating a mutually beneficial, member-focused collaboration that is right for today s health care environment. The 2014 AQI Cardiology and Obstetrics/Gynecology Quality Incentive Program will reward eligible physicians who render cardiology and obstetrics/gynecology services to our members, and meet or exceed established performance thresholds. It is just one more example of how we are working to fulfill our mission of improving the lives of the people we serve. We are committed to leading the way in improving the quality and affordability of health care benefits and delivery. The Program was developed to foster positive, collaborative relationships with our participating cardiology obstetrics/ gynecology physicians that will help enable us to promote improved health outcomes through an emphasis on quality cardiology and obstetrics/gynecology services. Who is eligible for the program? Physicians (MDs or DOs) who specialize in cardiology and obstetrics/gynecology and who are participating in our commercial networks. A physician group is defined as an organization at the tax identification number (TIN) level. A group may include one or more physicians. A physician group must have a minimum number of Anthem commercial members for each component or other criteria, as outlined in the chart on the following page, to be eligible for points related to that component of the program. This helps to ensure that we will be able to effectively and fairly assess the physician group. For those physicians who are part of a multi-specialty group, participation in this program is limited to those physicians in the group who are in the specialties listed above. Scoring and any compensation increases will be limited to those cardiology and obstetrics/gynecology physicians who are eligible to participate in the program. Physician groups that are part of an individually negotiated contract, such a PHOs and other entities, may not be eligible for the program. Anthem will use your current TIN found in our records as of December 31, 2014 for the final measurement and scoring process. A group office practice is defined as a medical office location under a TIN that is the primary place of service. A group is eligible for the program if at least one provider in the group is eligible as of December 31, What period of the time does the program cover? The measurement year for the program is January 1, 2014 through December 31, When will my performance results be available? Final performance results will be available by May 31, If you have any questions, please us at ppmne@anthem.com or contact your Network/ Provider Relations Consultant. 1

3 What are the program measures and eligibility criteria? Component Eligible Specialty Unique Criteria Required for Eligibility Within a TIN Clinical Quality Measures Care Management External Physician Recognition Clinical Improvement/Patient Centered Measures Resource Measures Generic Efficiency Rate Care Systems (Technology) Electronic Prescribing or CCHIT Technology Implementation American Imaging Management (AIM ) ProviderPortal SM Radiology Tool Adoption Availity Adoption OR Certified Electronic Health Record Technology that has met the Centers for Medicare & Medicaid Services (CMS) Meaningful Use Requirements. Cardiology & Obstetrics/Gynecology Cardiology Cardiology & Obstetrics/Gynecology Cardiology & Obstetrics/Gynecology Cardiology & Obstetrics/Gynecology 30 unique members, in total, for all measures combined in each composite Requires ten () members per measure to be scored in each composite (see scoring). Requires at least 25% of eligible physicians within a TIN to have an active External Physician Recognition during the measurement year (January 1, 2014 December 31, 2014). Requires at least one (1) physician within the TIN to have active participation in a state or national quality improvement collaborative or practice improvement activity during the measurement year (January 1, 2014 December 31, 2014). 25 minimum Express Scripts Inc. prescriptions filled for a Tax ID during measurement year (January 1, 2014 December 31, 2014) and only includes members with Express Scripts Inc. benefit. Requires at least one (1) group office practice (0% eligible physicians in that office practice) within the TIN to have at least one of the technologies implemented and in use prior to January 1, Requires at least one (1) user within a TIN has signed up and has used the American Imaging Management (AIM) ProviderPortal tool to prior authorize at least one health plan member by the last day of the measurement period. Requires at least one (1) user within a TIN has signed up and has access to Availity by the last day of the measurement period. Requires at least one (1) group office practice (50% eligible physicians in that office practice) within a TIN has implemented a Certified Electronic Health Record Technology that met the CMS Meaningful Use Requirements during the measurement year. 2

4 How were the measures developed? We use a variety of resources, including literature research for evidence-based guidelines, clinical health care experts and data analysis in the development of the set of clinical measures. The clinical quality measures have been derived from sources such as Healthcare Effectiveness Data and Information Set (HEDIS ). The methods used are consistent with those recommended by the National Committee for Quality Assurance (NCQA) and reflect the most current standards on measuring physician quality of care. HEDIS reporting is the standard for data collection and performance measurement of managed care organizations. CLINICAL QUALITY MEASURES The clinical quality measurement analysis is performed by Resolution Health, Inc., (RHI) utilizing its Physician Quality Profiler tool. RHI is a leading data analytics-driven personal health care guidance company that has complied evidence-based care guidelines and clinical best practices, sourced from organizations such as the NCQA, the American Heart Association (AHA), the American Diabetes Association (ADA), the Centers for Disease Control (CDC), the Food and Drug Administration (FDA), clinical literature and health care experts. Anthem administrative claims including professional, facility, pharmacy and laboratory will only be utilized in the Physician Quality Profile analysis. Final clinical quality scoring will be performed by Anthem at the TIN level. More information on RHI can be found on PREVENTIVE CARE AND SCREENING (Obstetrics and Gynecology) Women s Health Rationale The American Congress of Obstetricians and Gynecologists (ACOG) states prevention and early detection are the keys to reducing deaths from breast cancers and incidence of chlamydia infection. ACOG reported that breast cancer is the second leading cause of cancer death in the United States. According to the latest figures from the Centers for Disease Control and Prevention (CDC), approximately 211,731 women were diagnosed with breast cancer*. Chlamydia is a major cause of infertility, pelvic inflammatory disease (PID) and ectopic pregnancy in women, and the direct and indirect costs of these illnesses exceed $2 billion as historically reported by the Centers for Disease Control and Prevention. * Measures The percentage of women 42 to 69 years old who had a mammogram during the measurement year or year prior to measurement year. (Source: NCQA, HEDIS) The percentage of women 16 to 25 years old identified as sexually active that had at least one Chlamydia test during the measurement year. (Source: NCQA, HEDIS) The percentage of women age 21 to 64 who had at least one Pap test during the measurement year or during the two (2) years prior to the measurement year. (Source: NCQA, HEDIS) Percentage of women who suffered a bone fracture and had either a bone mineral density test (BMD) or prescription for a drug to either treat or prevent osteoporosis during the six months after the day of fracture. (Source: NCQA, HEDIS) 3

5 CARE MANAGEMENT (Cardiology) Heart Disease Rationale According to the latest data from the CDC, heart disease is the leading cause of death in the U.S. with about 600,000 deaths per year, with roughly 385,000 of those deaths being attributed to coronary heart disease. The annual estimated cost of coronary heart disease alone is roughly $9 billion. Cardiovascular conditions include coronary artery disease (CAD) and ischemic vascular disease (IVD). * Measure The percentage of patients 18 to 75 years old discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1 to November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during or in the year prior to the measurement year, who had an LDL-C check during the measurement year. (Source: NHLBI, 2004) Annual Monitoring of Members with Persistent Medication Use Measures The percentage of adults who are taking digoxin on a regular basis and have received a serum creatinine and potassium check during the measurement year. (Source: NCQA, HEDIS) The percentage of adults who are taking diuretics on a persistent basis with a serum potassium or creatine check during the measurement year. (Source: NCQA, HEDIS) Medication Compliance Rationale Compliance studies showed that only 63% of members with cardiovascular disease or diabetes are compliant with medications over a year and take their medication only 72% of the time. In 73% of the studies reviewed compliance had a positive effect on clinical outcomes which leads to a decrease in medical events and non-drug costs. Measures The percentage of members who were hospitalized for acute myocardial infarction (AMI) and discharged from the hospital between July 1 of the year prior to the measurement year and June 30 of the measurement year, and who have been on betablocker treatment for at least six (6) months post discharge. (Source: AQA, CMS-PQRI-, NCQA, MEDIS0 NQF) This measure identifies patients on a lipid medication who have remained adherent to taking the medication regularly. (Source: NQF) Rationale The NCQA reported that patient safety is highly important for members at increased risk of adverse drug events from longterm medication use. In addition, the NCQA notes persistent use of the drugs warrants monitoring and follow-up by the prescribing physician to assess for side effects and adjust drug dosage/therapeutic decisions accordingly. According to the NCQA, over $85 billion is spent per year to treat drug-related problems caused by misuse in the ambulatory setting. 4

6 EXTERNAL PHYSICIAN RECOGNITION In order to emphasize the clinical quality of care, physicians will receive points for the measure based on the successful completion of a clinical performance assessment program sponsored by either Bridges to Excellence (BTE) or the NCQA. More information is available at or Requires at least 25% of eligible physicians within the TIN have current active External Physician Recognition during the measurement year (January 1, 2014 December 31, 2014). Bridges to Excellence Cardiac Care Link (CCL) Congestive Heart Failure Care Link (CHFCL) COPD Care Link (COPDCL) Coronary Artery Disease Care Link (CADCL) National Committee for Quality Assurance Heart/Stroke Recognition Program (HSRP) *Please note: There are no external recognitions for obstetrics/gynecology physicians. Instead, Anthem will conduct evaluation of paid claims data using HEDIS measures. What information is required from practices for the External Physician Recognition Component? The External Physician Recognition Component will be scored based on the completion of a survey and a list of those physicians within the TIN that have a current active External Physician Recognition during the measurement year (January 1, 2014 December 31, 2014). The completed survey questions with attestation and list of physicians must be submitted to Anthem no later than February 28, Information on how to obtain the survey can be found on the following pages. RESOURCE MEASURES Generic Rate Rationale When used as a first line therapeutic option, generics may offer cost-effective treatment when prescribed appropriately. Moving from selected therapeutic classification to an overall generic efficiency rate measure allows physicians a greater opportunity in the measure. Measure The generic rate is based on the number of written and filled Express Scripts, Inc. (ESI) generic scripts (captured of each of the individual physicians then aggregated up to the TIN) as a percentage of the total number of scripts for a TIN during the measurement period. The overall generic rate will then be compared to their peer network state rate. Calculation is found below: Number of ESI generic prescriptions/total number of ESI prescriptions Resource Measures (Informational only) We believe in the importance of advancing transparency, data sharing and evaluating cost of as well as quality. Therefore, we will be looking to provide additional resource or cost performance information to participating AQI physicians during the coming year. Information we anticipate providing includes measures such as Emergency Room Utilization Measure potentially avoidable visits and, All Cause Readmission Rate. (Source: HEDIS) These measures will not be used in the Quality-In-Sights scoring this year, but may be included in future years with advanced notification. 5

7 CLINICAL IMPROVEMENT/ PATIENT-CENTERED MEASURES Anthem will continue to recognize applicable collaborative (statewide or national) or practice improvement activities that the physician or physicians practice participate in during the measurement period (January 1, 2014 December 31, 2014). A collaborative or practice improvement may include, but is not limited to, health plans, physicians, hospitals, employers, government agencies, quality improvement organizations or other entities working together to improve health care by implementing systems and processes that utilize evidence-based clinical standards. Requires at least one (1) provider within the TIN to have active participation in a quality improvement collaborative or practice improvement activity during the measurement year. National Initiative Examples (included but not limited to): National Committee for Quality Assurance (NCQA) PPC Patient-Centered Medical Home (PPC-PCMH) Bridges to Excellence (BTE) Medical Home What information is required for the Clinical Improvement/Patient-Centered Component? The Clinical Improvement/Patient-Centered Component will be scored based on the following: Completion of survey questions and a list of those physicians participating in the clinical collaborative(s) or practice improvement activities within the TIN. Clinical collaborative(s) or practice improvement activity program description, activities and results or certification within the TIN. CARE SYSTEMS (Technology) Rationale Appropriate technology care systems can improve the quality, safety, efficiency and care coordination of patient care and simplify transaction. Meaningful use of technology focuses on the effective use of Electronic Health Records with certain defined capabilities. The Centers for Medicare & Medicaid Services (CMS) Electronic Health Technology certification program requires that eligible professionals must successfully demonstrate meaningful use of a certified electronic health record technology every year they participate in the program. Measures Technologies Requires at least one (1) group office practice (0% physicians at the group office location) within the Tax ID to have at least one (1) of the following technologies implemented and in use prior to January 1, Electronic prescribing, or use of any CCHIT Certified Ambulatory EHR More information is available at 2. AIM ProviderPortal Radiology Adoption Requires at least one (1) user within a Tax ID has signed up and has used the AIM ProviderPortal tool to pre-certify for at least one (1) health plan member by the last day of the measurement period. The ProviderPortal utilizes an easy-to-use web tool, OptiNet, to facilitate rendering provider registration of equipment, services and staffing. Using its proprietary evaluation criteria, AIM uses this information to generate rendering provider value scoring which assists ordering physicians and members in determining where to receive imaging services. More information is available at The completed survey with attestation and additional program documentation must be submitted to Anthem for review and approval no later than February 28, 2015 to be considered in your score. For initiatives not explicitly listed above, Anthem may, in its sole discretion, determine that initiative qualify as acceptable collaborative activities for purposes of this program measure. 6

8 3. Availity Adoption* Requires at least (1) user within a TIN has signed up and has access to Availity by the last day of the measurement period. Availity offers a secure multi-plan portal at no charge to physicians and improves efficiencies in the health care system by simplifying many aspects of health plan administration an important step toward advancing affordable care. Availity s one-stop-shop approach benefits members, physicians and health plans by streamlining the health care administration process and providing a consistent user experience. *In the event that Availity is not available, the points attributed to that measure will be reassigned to applicable technology measures as appropriate. More information is available at OR Certified Electronic Health Records Technology that has met the CMS Meaningful Use Requirements Requires at least one group office practice (50% eligible physicians in that office practice) within a Tax ID has implemented a Certified Electronic Health Record Technology that has met the Centers for Medicare & Medicaid (CMS) Meaningful Use Requirements during the measurement year. Required support documentation: Certified Electronic Health Record Technology that has bet the Centers for Medicare & Medicaid (CMS) Meaningful Use Requirements submitted to Health plan prior no later than February 28, The table below provides only a few examples of Meaningful Use Requirements; please refer to the CMS website at for the complete MCS Meaningful Use Requirements.The table below provides only a few examples of Meaningful Use Requirements; please refer to the CMS website at for the complete MCS Meaningful Use Requirements. Meaningful Use Examples ONLY (not complete set of requirements) Record patient demographics (sex, race, ethnicity, date of birth, preferred language, and in the case of hospitals, date and preliminary cause of death in the event of mortality) Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children) Maintain up-to-date problem list of current and active diagnoses Maintain active medication list Maintain active medication allergy list Record smoking status for patients 13 years of age or older For individual professionals, provide patients with clinical summaries for each office visit; for hospitals, provide an electronic copy of hospital discharge instructions on request On request, provide patients with an electronic copy of their health information (including diagnostic test results, problem, list, medication lists, medication allergies, and for hospitals, discharge summary and procedures) Generate and transmit permissible prescriptions electronically (does not apply to hospitals) Computer provider order entry (CPOE) for medication orders Implement drug-drug and drug-allergy interaction checks Implement capability to electronically exchange key clinical information among Implement one clinical decision support rule and ability to track compliance with the rule Implement systems to protect privacy and security of patient data in the Electronic Health Record Report clinical quality measures to CMS or states 7

9 What information is required from practices for the Care Systems Component? The Care Systems Component will be scored based on the completion of survey questions, a list of those physicians within the group office practice that have implemented and used the technology prior to January 1, 2015 and applicable external certification documentation.* The completed survey with attestation and required support documentation must be submitted to Anthem no later than February 28, *Please note: There are no external recognitions for obstetrics/ gynecology physicians. Instead, Anthem will conduct evaluation of paid claims data using HEDIS measures. Where is the required survey located? The required online survey for the External Physician Recognition, Clinical Improvement and Care Systems component questions will be available in June 2014 at the specialty-specific links as follows: OBGYN survey: Cardiology: The online survey is completed once for all group practice locations under a single TIN. Multiple specialty practices with the specialties of cardiology and OBGYN within the same tax ID should complete one survey for each specialty. The completed online survey with attestation must be submitted to Anthem no later than January 28, 2015 via to ppmne@anthem.com. 8

10 MEASUREMENT How are the measurements scored? Each provider/group will be scored on their aggregate points. The maximum achievable points are 0. The charge below depicts the maximum achievable points for each component. Cardiology Program Components: Maximum Points Clinical Quality Measures Composite Care Management Measures 50 OR External Physician Recognition 50 one (1) recognition (35 pts) two (2) recognitions (50 pts) Generic Efficiency Rate 15 Clinical Improvement 5 Care Systems 30 Electronic Prescribing or CCHIT Technology Implementation ( pts) AIM ProviderPortal Radiology Adoption ( pts) Availity Adoption ( pts) OR Current certification regarding implementation of Electronic Health Record Technology that has met the CMS Meaningful Use Requirements (30 pts) Maximum Points Available 0 } Obstetrics/Gynecology Program Components: Maximum Points Clinical Quality Measures Composite 50 Preventive Care Measures Generic Efficiency Rate Composite 15 Clinical Improvement 5 Care Systems 30 Electronic Prescribing or CCHIT Technology Implementation ( pts) AIM ProviderPortal Radiology Adoption ( pts) Availity Adoption ( pts) OR Current certification regarding implementation of Electronic Health Record Technology that has met the CMS Meaningful Use Requirements (30 pts) Maximum Points Available 0 * Physicians are eligible for points in either the Care Management measures or the External Physician Recognition measures in the Clinical Quality composite section. The Care Management or External Physician Recognition measures with the highest total point value (maximum of 30) will be included in the final scoring. 9

11 When and how is the quality incentive paid? The 2014 Quality-In-Sights Cardiology and Obstetrics/ Gynecology Incentive program will reward qualifying physicians through an incentive to applicable payments over the period of July 1, 2015 through June 30, Total Points Achieved Adjustment to Fee Schedule % % % For physicians in a group practice, the eligibility criteria and performance results of all physicians in the group will be aggregated at the TIN level. The above rewards are non-cumulative, and a group cannot qualify for more than one fee enhancement. In multi-specialty group, any fee enhancement will apply only to the cardiology and obstetrics/gynecology physicians in the group. Who do I contact with questions? If you have any questions about the Anthem s 2014 Pay for Performance Program, please us at ppmne@anthem.com.

12 Quality-In-Sights Cardiology and Obstetrics/Gynecology Incentive Program 2014 Goals and Scoring Cardiology Clinical Quality Composite Care Management * Requires the following in order to be scored: a. 30 overall unique members for a TIN b. members per measure for a TIN Measures Goals - points distributed equally among measures that meet the minimum member threshold Heart Disease - Requires at least members per measure - Cholesterol Management LDL-C Testing, Beta Blocker Therapy Medication Compliance - ACE Inhibitor - Post-MI Each measure group rate must be greater than or equal to the 50 th percentile target and below the 75 th 30 percentile target. Each measure group rate must be greater than or equal to the 75 th percentile target and below the 90 th 40 percentile target. Each measure group rate must be greater than or equal to and above the 90 th percentile target. 50 Maximum 50 Care Management Point Distribution (based on the number of measures that meet the minimum member threshold) # Measures that meet the minimum member threshold Points per measure group rate that is equal to the 50 th percentile and below the 75 th percentile Points per measure group rate that is equal to the 75 th percentile and below the 90 th percentile Points per measure group rate that is equal to and above the 90 th percentile (30 maximum points) (40 maximum points) (50 maximum points) *Scored on either Care Management Measures or External Physician BTE or NCQA Physician Recognition Programs. 11

13 External Physician Recognition Composite External Physician Recognition (BTE or NCQA) Measure Goals and Scoring At least 25% of the eligible physicians in a TIN need to have one (1) active external physician recognition during the measurement period (January 1, 2014 December 31, 2014). At least 25% of the eligible physicians in a TIN need to have two (2) active external physician recognitions during the measurement period (January 1, 2014 December 31, 2014). Generic Pharmacy Composite - Members must have active Express Scripts benefits during the measurement period. Must have at least 25 Express Scripts prescriptions for a TIN dispensed in order to be measured. Generic Efficiency Rate - Note: Comparison peer network is made up of the eligible physicians in the AQI program within each state Clinical Improvement Composite Greater than or equal to the 75 th percentile and below the 90 th percentile of the comparison peer network Greater than or equal to the 90 th percentile of the comparison peer network Measure Goals and Scoring Clinical Improvement Collaborative Activity - Submission of supportive documentation and survey questions is required. Care Systems Composite A TIN must have at least one (1) provider that has actively participated in a Collaborative Clinical Collaborative between January 1, 2014 December 31, Measure Goals and Scoring Implementation and use of Electronic-Prescribing or Implementation and use of any CCHIT Certified Ambulatory EHR AIM ProviderPortal Radiology Adoption Availity Adoption Certified Electronic Health Record Technology that has met the CMS Meaningful Use Requirements. A TIN must have at least one (1) entire group office practice (0% physicians at the group office location) implemented and is in use prior to January 1, Requires at least one (1) user within a TIN has signed up and has used the AIM ProviderPortal tool to pre-certify for at least one (1) health plan member by the last day of the measurement period. Requires at least 1 user within a TIN has signed up and has access to Availity by the last day of the measurement period. OR Requires at least one (1) group office practice (50% eligible physicians in that office practice) within a TIN has implemented a Certified Electronic Health Record Technology that met the Centers for Medicare & Medicaid (CMS) Meaningful Use Requirements during the measurement year Maximum Maximum 5 5 Maximum Total Maximum Composite Points

14 Obstetrics/Gynecology Clinical Quality Composite Preventive Care and Screening Requires the following in order to be scored: a. 30 overall unique members for a TIN b. members per measure for a TIN Goals - points distributed equally among measures Measures that meet the minimum member threshold Women s Health Requires at least members per measure Breast CA screening, Chlamydia screening, Osteoporosis therapy Each measure group rate must be greater than or equal to the 50 th percentile target and below the 75 th percentile target. Each measure group rate must be greater than or equal to the 75 th percentile target and below the 90 th percentile target. Each measure group rate must be greater than or equal to and above the 90 th percentile target. Preventive Care & Screening Point Distribution (based on the number of measures that meet the minimum member threshold) # Measures that meet the minimum member threshold Points per measure group rate that is equal to the 50 th percentile and below the 75 th percentile Points per measure group rate that is equal to the 75 th percentile and below the 90 th percentile (30 maximum points) (40 maximum points) Points per measure group rate that is equal to and above the 90 th percentile (50 maximum points) Maximum 50 13

15 Generic Pharmacy Composite - Members must have active Express Scripts benefits during the measurement period. Must have at least 25 Express Scripts prescriptions for a TIN dispensed in order to be measured Generic Efficiency Rate - Note: Comparison peer network is made up of the eligible physicians in the AQI program within each state Clinical Improvement Composite Greater than or equal to the 75 th percentile and below the 90 th percentile of the comparison peer network Greater than or equal to the 90 th percentile of the comparison peer network 15 Measure Goals and Scoring Maximum Clinical Improvement Collaborative Activity - Submission of supportive documentation and survey questions is required. Care Systems Composite A TIN must have at least one provider that has actively participated in a Collaborative Clinical Collaborative between January 1, 2014 December 31, Measure Goals and Scoring Maximum Implementation and use of Electronic- Prescribing or Implementation and use of any CCHIT Certified Ambulatory EHR AIM ProviderPortal Radiology Adoption Availity Adoption Certified Electronic Health Record Technology that has met the CMS Meaningful Use Requirements A TIN must have at least one (1) entire group office practice (0% physicians at the group office location) implemented and is in use prior to January 1, Requires at least one (1) user within a TIN has signed up and has used the AIM ProviderPortal tool to pre-certify for at least one (1) health plan member by the last day of the measurement period. Requires at least one (1) user within a TIN has signed up and has access to Availity by the last day of the measurement period. OR Requires at least one (1) group office practice (50% eligible physicians in that office practice) within a TIN has implemented a Certified Electronic Health Record Technology that met the Centers for Medicare & Medicaid (CMS) Meaningful Use Requirements during the measurement year. Total Maximum Composite Points Under no circumstances shall physicians or groups withhold medically necessary or medically appropriate care in order to meet or exceed the above measures. HEDIS is registered trademark of the National Committee for Quality Assurance 14

16 Anthem Blue Cross and Blue Shield is the trade name of: In Connecticut: Anthem Health Plans, Inc. In Maine: Anthem Health Plans of Maine, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.