20-178 Patient Assessment Form No Longer Needed to Get Incentive

Date: 02/24/20

This information applies to Participating Physician Groups (PPGs).

Paid claims from annual wellness visits will be used for CommunityCare Medical Loss Ratio Incentive Program

Fee-for-service participating physician groups (PPGs) in CommunityCare will no longer need to fill out and submit a Patient Assessment Form (PAF) for the health assessment measure of the Medical Loss Ratio (MLR) Incentive Program. Health Net will calculate the incentives based on paid claims from members’ annual wellness visits (AWVs). This will reduce the administrative burden on the physicians and allow a faster and more accurate way of reconciling the data for the incentives using information already being submitted through the claims payment system. Health Net will continue to give the target member list via email, quarterly starting in March.

AWV qualifying codes

To qualify, the AWV must be coded with one of the codes listed below and submitted for each member via professional encounter or claims.

• CPT codes: 9938X, 9939X, 99213, 99214, 99215, 99203, 99204, 99205, with lipids panel test (80061) up to one week before or 30 days after the visit.
• Exam diagnosis (DX) codes: ICD-10: Z00.00, Z00.5, Z00.6, Z00.8, Z02.1, Z02.3, Z02.81, Z02.83, Z02.89, Z04.6.

AWV goals

AWV addresses and ensures all member conditions are identified, documented and managed. The incentive program seeks to accomplish three goals:

1     Early detection of member chronic conditions.

2     Complete and accurate documentation of members with chronic conditions.

3     Active and comprehensive care management of members with chronic conditions.

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Risk Adjustment Operations Department by email at HNCARiskAdjustmentOps@healthnet.com.