Blue Distinction Centers for Cardiac Care 2018 Provider Survey

Transcription

1 Blue Distinction Centers for Cardiac Care 2018 Provider Survey Printed version of this document is for reference purposes only. Paper copies of the Provider Survey and Team Table will not be accepted. A completed Provider Survey and Team Table must be submitted via the online web application Blue Distinction Portal SM (BD Portal SM ). Review the instructions below for completion of both the Provider Survey and Team Table via online web application BD Portal. Part 1: Provider Survey Question Numbers Facility Information 1-8 Cardiac Care Program Information Cardiac Program Structure Percutaneous Coronary Intervention (PCI) Acute Myocardial Infarction (AMI) Care Cardiothoracic Surgery Part 2: Team Table Physician and Surgeon Information Terms & Conditions Not Applicable Not Applicable TE: In addition to Part 1: Provider Survey, facilities must also complete Part 2: Team Table via BD Portal to complete the application. Please complete Part 2: Team Table via the Survey Actions tab in BD Portal. PART 1: PROVIDER SURVEY This is the Quality based evaluation process for Blue Distinction Centers for Cardiac Care designation. Please complete all Provider Survey information pertaining to your facility s current and active cardiac care services for adults (18 years and older). Please be sure that your survey is complete before submitting. Additional program materials for the Blue Distinction Centers for Cardiac Care program are available at: Please pay attention to all special instructions for formats when entering numerical responses. Here are a few examples: BDCC040_ _FINAL 1

2 Percentages: The response of five percent should be entered as: 5 % [TE you should T enter this as 0.05 in the data entry box] Decimal Places: For some survey responses, numbers may include up to 2 s. For example, PCI in-hospital risk adjusted mortality (all patients) = 1.85 [where the question directs you to provide a figure from with 2 s] FACILITY INFORMATION VI FACILITY ADDRESS AND IDENTIFIERS WILL BE PRE-POPULATED IN THE ONLINE VERSION OF THIS SURVEY. FACILITY NAME: ADDRESS: If any of the Facility Information shown above is incorrect, please Raise a Case in BD Portal or contact your local Blue Cross and/or Blue Shield Plan contact directly to have the information corrected. Also, please review your National Provider Identifier (NPI), Federal Tax Identification Number (FEIN) and CMS Certification Number (CMS ID) on your Facility Record in BD Portal to confirm accuracy. To access your Facilty Record, click on your facility name on the Survey Actions tab in BD Portal. If any of the facility identifiers shown on the Details sub-tab are incorrect, please Raise a Case in BD Portal or contact your local Blue Cross and/or Blue Shield Plan directly to have the information corrected. Instructions on how to Raise a Case outlined in the BD Portal: Quick Reference Guide for Facility Users posted in the Document Library in BD Portal. 1. Please provide the following information for the person responsible for completing and submitting this Provider Survey: Primary Contact Name: Title: Phone: 2. Please provide your facility s legal contact. This individual may be contacted in the event there are questions related to potential brand conflicts that need to be addressed. Facility Legal Counsel/Representative Contact: Name: Title: Phone: BDCC040_ _FINAL 2

3 3. The Blue Distinction Centers for Cardiac Care designation is given only to individual facilities (i.e., unique bricks and-mortar facilities with unique addresses). Any facility with multiple locations (different addresses) must complete a separate Provider Survey for each location. Health systems and other groups of multiple facilities will not be designated collectively. 3a. Is the Quality information submitted in this Survey (e.g., accreditations, volume, outcomes) only for the single facility whose name and address are listed in the Provider Information Section, above, and for no other facilities or locations? YES If, please explain. 3b. The evaluation of Blue Plans healthcare claims data requires distinct provider identifiers to be present on submitted claims in order to match them back to your facility s application. Are claims submitted by your facility to your Blue Plan clearly distinguished from other facilities by using a distinct facility name, distinct Tax ID, distinct NPI, and distinct Plan Provider ID? If you do not have insight on this question, simply answer DO T KW. This is for informational purposes only. YES DO T KW If or DO T KW, please provide guidance on the best method for distinguishing your facility s claims. 4. Does your facility share a National Provider Identifier (NPI) with another facility (or facilities)? YES (Complete Question 4a) 4a. If YES, please provide each facility s name(s) and address (es). 5. Does your facility share a Tax ID with another facility (or facilities)? YES (Complete Question 5a) 5a. If YES, please provide each facility s name(s) and address (es). 6. Does your facility share a CMS Certification Number with another facility (or facilities)? YES (Complete Question 6a) 6a. IF YES, please provide each facility s name(s) and address (es). 7. Please indicate which of the following statements describes your facility's current accreditation status: (Check ALL that apply) My facility is fully accredited (without provision or condition) by The Joint Commission (TJC) in the Hospital Accredited Program. BDCC040_ _FINAL 3

4 My facility is fully accredited by Healthcare Facilities Accreditation Program (HFAP) of the Accreditation Association for Hospital and Health Systems (AAHHS) as an acute care hospital. My facility is fully accredited by DNV GL Healthcare in the National Integrated Accreditation for Healthcare Organizations (NIAHO ) Hospital Accreditation Program. My facility is fully accredited by the Center for Improvement in Healthcare Quality (CIHQ) in the Hospital Accreditation Program. My facility is not fully accredited by any of the above organizations. 8. Is your facility a comprehensive acute care facility that offers ALL of the following services on site? Intensive care unit; Emergency Room or Emergency Services that include plans or systems for onsite emergency; Admission of post-operative patients with 24/7 availability of onsite medical response teams; 24/7 availability of in-house emergency physician coverage; Diagnostic radiology including MRI and CT; 24/7 availability of inpatient pharmacy services (may include alternative nighttime access when pharmacy is closed); Blood bank or 24/7 access to blood bank services; AND 24/7 availability of Clinical Laboratory Improvement Amendments (CLIA) accredited laboratory services. YES If, please explain. CARDIAC CARE PROGRAM INFORMATION Questions in this section that refer to my, your, my facility s or your facility s program all refer to your facility s own cardiac care program (not the Blue Distinction Centers for Cardiac Care program). Refer to the Supplemental Instructions to help complete the Cardiac Care Program Information section. Cardiac Program Structure 9. Is your facility s cardiac care program accredited or certified in one of the following: (Check ALL that apply) The Joint Commission (TJC) Comprehensive Cardiac Care (CCC) Certification American Heart Association (AHA) Heart Attack STEMI Receiving Center Accreditation American Heart Association (AHA) Heart Attack STEMI Referring Center Accreditation American College of Cardiology and American Heart Association Accreditation for Cardiovascular Center of Excellence (CVCOE) BDCC040_ _FINAL 4

5 American College of Cardiology (ACC) Chest Pain Center Accreditation American College of Cardiology (ACC) Cardiac Cath Lab Accreditation American College of Cardiology (ACC) Heart Failure Accreditation American College of Cardiology (ACC) Atrial Fibrillation Accreditation My facility is not currently fully accredited or certified by any of the organizations above. 10. Is your facility s cardiac rehabilitation program (or the cardiac rehabilitation program your facility refers patients to) certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)? YES (Complete Question 10a) 10a. Does your facility s cardiac rehabilitation program (or the cardiac rehabilitation program your facility refers patients to) participate in the AACVPR Cardiac Rehabilitation (CR) Registry? YES 11. Does your facility s cardiac rehabilitation program include the following Best Practices: (Check ALL that apply) Automatic or default referral of eligible patients to cardiac rehabilitation Cardiac Rehabilitation Liaison to assist in discharge, referrals, timely enrollment, and patient education Track cardiac rehabilitation enrollment Track cardiac rehabilitation participation Track cardiac rehabilitation enrollment and participation by demographics Patient satisfaction scores are collected by the cardiac rehabilitation center Accommodations made to increase cardiac rehabilitation referrals and participation in heart failure patients My facility s cardiac rehabilitation program does not follow any of the above Best Practices. Percutaneous Coronary Intervention (PCI) 12. Does your facility report to the National Cardiovascular Data Registry (NCDR ) CathPCI Registry AND has your facility reported on ALL Adult Percutaneous Coronary Intervention (PCI) procedures performed at your facility from July 1, 2016 through June 30, 2017? YES (Complete Question 12a) 12a. Does your facility participate in the CathPCI Registry Public Reporting on American College of Cardiology (ACC) Cardiosmart? Cardiosmart Find-Your-Heart-a-Home YES BDCC040_ _FINAL 5

6 13. Does your facility have the CathPCI Registry Institutional Outcomes Report 2017Q2, including four (4) consecutive quarters of data, where Yes is marked under Included in Executive Summary for having passed ALL CathPCI Registry data quality report checks in the Inclusion Summary on page 3? YES (Complete Questions 13a 13n) Questions 13a through 13n require data from your facility s CathPCI Registry Institutional Outcomes Report 2017Q2. Refer to both the Executive Summary and Detailed Section of your facility s CathPCI Registry Institutional Outcomes Report 2017Q2 to answer the following questions. the following data elements for each of the Performance/Outcome Measures listed below from the My Hospital R4Q (rolling four (4) quarters) column of the Detailed Section of the report (refer to provided in each question). Note: Only enter zero (0) if the reported metric unit (Numerator, Denominator and/or Result) is zero (0). If any of the reported metric units requested are blank, choose the radio button indicating there are no 13a. PCI Procedure Volume My Hospital RQ4 ( Numerator Value) #1013 PCI My facility does not have 13b. Executive Summary Measure #1: PCI In-Hospital Risk Adjusted Mortality (All Patients) My Hospital R4Q ( Numerator Value) #2032 Eligible pts My facility does not have #2036 Risk Adjusted Mortality Rate (%) #2038 Lower 95% confidence interval #2039 Upper 95% confidence interval s) s) s) My facility does not have My facility does not have My facility does not have 13c. Executive Summary Measure #4: Proportion of STEMI Patients Receiving Immediate PCI w/in 90 Minutes #1503 Door to balloon times (excluding transfers and pts w/ a reason for delay) <= 90 minutes Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. BDCC040_ _FINAL 6

7 13d. Executive Summary Measure #9: Proportion of Patients with a P2Y12 Inhibitor Prescribed at Discharge #2006 Among pts w/ stents Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13e. Executive Summary Measure #10: Statins Prescribed at Discharge #2002 Statins Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13f. Executive Summary Measure #12: Emergency CABG Post PCI #1980 Emergency CABG post PCI Procedure Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13g. Executive Summary Measure #16: Proportion of PCI with Post Procedure Stroke #1811 Patients w/out CABG during Admission Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13h. Executive Summary Measure #18: PCI In-Hospital Risk Adjusted Mortality (Patients with STEMI) My Hospital R4Q ( Numerator Value) #2041 Eligible pts #2045 Risk Adjusted Mortality Rate (%) #2047 Lower 95% confidence interval #2048 Upper 95% confidence interval s) s) s) 13i. Executive Summary Measure #19: PCI In-Hospital Risk Adjusted Mortality (STEMI patients excluded) My Hospital R4Q ( Numerator Value) #2050 Eligible pts My facility does not have My facility does not have My facility does not have My facility does not have My facility does not have BDCC040_ _FINAL 7

8 #2054 Risk Adjusted Mortality Rate (%) #2056 Lower 95% confidence interval #2057 Upper 95% confidence interval s) s) s) My facility does not have My facility does not have My facility does not have 13j. Executive Summary Measure #30: Proportion of PCI Not Classifiable for Appropriate Use Criteria (AUC) Reporting #1589 PCIs not classifiable for AUC reporting Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13k. Executive Summary Measure #36: Patients WITHOUT Acute Coronary Syndrome: Proportion of Evaluated PCI that were Inappropriate #1587 Inappropriate (Among evaluated PCIs) Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. 13l. Executive Summary Measure #37: PCI In-Hospital Risk Adjusted Rate of Bleeding Events (All Patients) My Hospital R4Q ( Numerator Value) #1819 Eligible pts My facility does not have #1823 Risk adjusted bleeding event rate (%) #1825 Lower 95% confidence interval #1826 Upper 95% confidence interval s) s) s) My facility does not have My facility does not have My facility does not have 13m. Executive Summary Measure #38: Composite Discharge Medications in Eligible PCI Patients #2007 Therapy with aspirin, P2Y12 inhibitor, and statin at discharge following PCI in eligible patients Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not measure. BDCC040_ _FINAL 8

9 13n. Cardiac Referral provided at Discharge for PCI Patients Proportion of PCI patients referred for cardiac rehabilitation referral #1990 Cardiac Rehabilitation Referral Numerator Whole Number My Hospital RQ4 Denominator Percentage % (Up to 2 s) My facility does not Acute Myocardial Infarction (AMI) Care 14. Does your facility report to the National Cardiovascular Data Registry (NCDR ) ACTION Registry AND has your facility reported on ALL eligible Acute Myocardial Infarction (AMI) episodes at your facility from July 1, 2016 through June 30, 2017? YES (Complete Question 14a) 14a. Does your facility have the ACTION Registry Institutional Outcomes Report 2017Q2, including 4 consecutive quarters of data, where Yes is marked under Included in Executive Summary for having passed ALL ACTION Registry data quality report checks in the Inclusion Summary on page 3? YES (Complete Question 14b) Question 14b requires data from your facility s ACTION Registry Institutional Outcomes Report 2017Q2. Refer to both the Executive Summary and the Detail Section of your facility s ACTION Registry Institutional Outcomes Report 2017Q2 to answer the following questions. the following data elements for the Cardiac Rehabilitation Referral Measure below from the My Hospital R4Q column of the Detail Section of the report (refer to provided in each question). Note: Only enter zero (0) if the reported metric unit (Numerator, Denominator and/or Result) is zero (0). If any of the reported metric units requested are blank, choose the radio button indicating there are no 14b. Executive Summary Measure #21: Cardiac Rehabilitation Referral from an inpatient setting Proportion of AMI patients that received a cardiac rehabilitation referral #1021 #1886 #2256 Cardiac Rehabilitation Referral All Patients Cardiac Rehabilitation Referral STEMI Cardiac Rehabilitation Referral NSTEMI Numerator My Hospital RQ4 Denominator Percentage % (Up to 2 s) (Up to 2 s) (Up to 2 s) My facility does not My facility does not My facility does not BDCC040_ _FINAL 9

10 Cardiothoracic Surgery (CABG and Valves) 15. Do all cardiothoracic surgeons with cardiac surgical privileges at your facility participate in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) AND submit data on ALL Coronary Artery Bypass Graft (CABG), Aortic Valve Rement (AVR), and Mitral Valve Repair/Rement (MVRR) procedures performed at your facility, and is ALL such data reported in the STS ACSD Submission 3 Report, period ending June 30, 2017? YES (Complete Question 15a) (Skip to Attestation) 15a. Does your facility participate in the Adult Cardiac Surgery Database (ACSD) Public Reporting? STS Public Reporting YES 16. Does your facility have the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) 2017 Submission 3 Report (period ending June 30, 2017)? Yes (Complete Questions 16a 16k) No (Skip to Attestation) 16a. Participating Group Number: (numerical entry) Note: Cardiovascular Surgeons practicing at your facility may have more than one Participating Group Number, in which the cardiovascular surgeon groups report separately, and therefore receive separate STS ACSD 2017 Submission 3 Reports. This is T common. If your cardiovascular surgeon groups do report separately and have more than one Participating Group Number and STS ACSD 2017 Submission 3 Report (period ending June 30, 2017), then you will need to complete Question 17 regarding this separate report which is different from the report being used to complete this section (Questions 16a 16k). Questions 16b through 16k require data from your facility s Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) 2017 Submission 3 Report (period ending June 30, 2017), released October 2017 OR the facility may use the STS Dashboard for the same reporting timeframe (period ending June 30, 2017), to complete Questions 16b through 16k. the following quality data elements from each of the specified sections of your report: STS Composite Quality Rating, Data Summary, and STS Composite Quality Rating Domain Details. Note: Only enter zero (0) if the reported metric unit (Numerator, Denominator and/or Result) is zero (0). If any of the reported metric units requested are blank, choose the radio button indicating there are no BDCC040_ _FINAL 10

11 Isolated Coronary Artery Bypass Graft (CABG) 16b. the number of cases for Isolated Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Isolated Coronary Artery Bypass Graft (CABG) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ c. the following quality measure detailed information for Isolated Coronary Artery Bypass Graft (CABG) procedures using the STS CABG Composite Quality Rating and STS CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. CABG Quality Domains Overall Mortality Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Morbidity Use of Internal Mammary Artery (IMA) Medications BDCC040_ _FINAL 11

12 Isolated Aortic Valve Rement (AVR) 16d. the number of cases for Isolated Aortic Valve Rement procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Isolated Aortic Valve Rement (AVR) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ e. the following quality measure detailed information for Isolated Aortic Valve Rement (AVR) procedures using the STS AVR Composite Quality Rating and STS AVR Composite Quality Rating Domain Details sections of your Submission 3 Report. AVR Quality Domains Mortality Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS AVR Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Morbidity Mitral Valve Repair/Rement (MVRR) 16f. the number of cases for Mitral Valve Repair/Rement (MVRR) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Mitral Valve Repair/Rement (MVRR) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/2017 BDCC040_ _FINAL 12

13 16g. the following quality measure detailed information for Mitral Valve Repair/Rement (MVRR) procedures using the STS MVRR Composite Quality Rating and STS MVRR Composite Quality Rating Domain Details sections of your Submission 3 Report. MVRR Quality Domains Mortality Morbidity Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS MVRR Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Combined Valve (AVR and MVRR) and Coronary Artery Bypass Graft (CABG) 16h. the number of cases for Combined Aortic Valve Rement (AVR) and Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Combined AVR + CABG My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ i. the following quality measure detailed information for Combined Aortic Valve Rement (AVR) and Coronary Artery Bypass Graft (CABG) procedures using the STS AVR+CABG Composite Quality Rating and STS AVR+CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. BDCC040_ _FINAL 13

14 AVR + CABG Combined Quality Domains Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS AVR + CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Mortality Morbidity 16j. the number of cases for Combined Mitral Valve Repair/Rement (MVRR) and Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Combined MVRR + CABG My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ k. the following quality measure detailed information for Combined Mitral Valve Repair/Rement (MVRR) and Coronary Artery Bypass Graft (CABG) procedures using the STS MVRR+CABG Composite Quality Rating and STS MVRR+CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. MVRR + CABG Combined Quality Domains Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS MVRR + CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Mortality Morbidity BDCC040_ _FINAL 14

15 Cardiothoracic Surgery (CABG and Valves) ADDITIONAL REPORT 17. Does your facility have more than one Cardiothoracic Surgery Group that has a separate Participating Surgeon Group Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) 2017 Submission 3 Report (period ending June 30, 2017), different than the one reported in questions 16a through 16k? YES (Complete Questions 17a 17k) (Skip to Attestation) 17a. additional Participating Group Number (should be different than 16a): (numerical entry) Note: Cardiovascular Surgeons practicing at your facility may have more than one Participating Group Number, in which the cardiovascular surgeon groups report separately and therefore receive separate STS ACSD 2017 Submission 3 Reports. This is not common. If your cardiovascular surgeon groups do report separately and have more than one Participating Group Number and STS ACSD 2017 Submission 3 Report, then check Yes for Question 17 regarding this separate report, which is different from the report used to complete the previous section (Questions 16a 16k). Questions 17b through 17k require data from your facility s Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) 2017 Submission 3 Report (period ending June 30, 2017), released October 2017 OR the facility may use the STS Dashboard for the same reporting timeframe, (period ending June 30, 2017), to complete Questions 17b through 17k. the following quality measure data elements from each of the specified sections of your report: STS Composite Quality Rating, Data Summary, and STS Composite Quality Rating Domain Details/ Data Summary. Note: Only enter zero (0) if the reported metric unit (Numerator, Denominator and/or Result) is zero (0). If any of the reported metric units requested are blank, choose the radio button indicating there are no Isolated Coronary Artery Bypass Graft (CABG) ADDITIONAL REPORT 17b. the number of cases for Isolated Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Isolated Coronary Artery Bypass Graft (CABG) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/2017 BDCC040_ _FINAL 15

16 17c. the following quality measure detailed information for Isolated Coronary Artery Bypass Graft (CABG) procedures using the STS CABG Composite Quality Rating and STS CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. CABG Quality Domains Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Overall Mortality Morbidity Use of Internal Mammary Artery (IMA) Medications Isolated Aortic Valve Rement (AVR) ADDITIONAL REPORT 17d. the number of cases for Isolated Aortic Valve Rement procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Isolated Aortic Valve Rement (AVR) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ e. the following quality measure detailed information for Isolated Aortic Valve Rement (AVR) procedures using the STS AVR Composite Quality Rating and STS AVR Composite Quality Rating Domain Details sections of your Submission 3 Report. BDCC040_ _FINAL 16

17 AVR Quality Domains Mortality Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS AVR Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Morbidity Mitral Valve Repair/Rement (MVRR) ADDITIONAL REPORT 17f. the number of cases for Mitral Valve Repair/Rement (MVRR) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Mitral Valve Repair/Rement (MVRR) My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ g. the following quality measure detailed information for Mitral Valve Repair/Rement (MVRR) procedures using the STS MVRR Composite Quality Rating and STS MVRR Composite Quality Rating Domain Details sections of your Submission 3 Report. MVRR Quality Domains Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) STS MVRR Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe Mortality Morbidity BDCC040_ _FINAL 17

18 Combined Valve (AVR and MVRR) and Coronary Artery Bypass Graft (CABG) ADDITIONAL REPORT 17h. the number of cases for Combined Aortic Valve Rement (AVR) and Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Combined AVR + CABG My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/ i. the following quality measure detailed information for Combined Aortic Valve Rement (AVR) and Coronary Artery Bypass Graft (CABG) procedures using the STS AVR+CABG Composite Quality Rating and STS AVR+CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. AVR+CABG Quality Domains Mortality Morbidity Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) Drop Down Box: Drop Down Box: STS AVR + CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe 17j. the number of cases for Combined Mitral Valve Repair/Rement (MVRR) and Coronary Artery Bypass Graft (CABG) procedures using the Data Summary section of the 2017 Submission 3 Report. Time Period Number of Cases for Combined MVRR + CABG My facility is unable to report results for this 2015 (1/1/ /31/2015) 2016 (1/1/ /31/2016) 1/1/2017 6/30/2017 BDCC040_ _FINAL 18

19 17k. the following quality measure detailed information for Combined Mitral Valve Repair & Rement (MVRR) and Coronary Artery Bypass Graft (CABG) procedures using the STS MVRR+CABG Composite Quality Rating and MVRR+CABG Composite Quality Rating Domain Details sections of your Submission 3 Report. MVRR+CABG Quality Domains Mortality Morbidity Score Score (98% Interval) Lower Limit (LCL) Upper Limit (UCL) Rating Star Rating (Choose from the drop down) Drop Down Box: Drop Down Box: STS MVRR + CABG Composite Quality Rating Domain Details # Eligible My facility is unable to report results for this measure/ timeframe BDCC040_ _FINAL 19

20 PART 2: TEAM TABLE In addition to Part 1: Provider Survey, facilities must also complete Part 2: Team Table via BD Portal to complete the application. Physician/Surgeon Team Table Please complete the Team Table for ALL Physicians and/or Surgeons who have privileges AND are actively performing the applicable services at your facility. Exclude physicians/surgeons who are no longer at your facility at the time of this application s submission. Exclude s physicians/surgeons who are or will be leaving/retiring prior to the time of this application s submission. Exclude physicians/surgeons who do T treat or manage any adult patients (ages 18 and older) at your facility at the time of this application s submission. There are two options to provide the requested information: Option 1 Download an Excel template to enter Physician/Surgeon names and upload the template to automatically populate the Team Table OR Option 2 Manually enter each Physician/Surgeon name one at a time using the form below. Option 1 Download and Upload Template Step 1 - Click Download Template and open the file in Excel. Complete a row for each Surgeon or Physician; make sure the 'Type' column contains only the word Physician" or "Surgeon. Save the completed Excel spreadsheet as a CSV file to your computer, as you will need to upload it into BD Portal in Step 2. Step 2 - Browse your computer to locate the saved Excel CSV file. Step 3 - Once you have located the saved Excel file on your computer, click the Upload Template button. Note: Uploading a template will over-write existing information in the table below. Option 2 Manually Using Form Step 1 - Manually enter Physician or Surgeon information into the form below. Step 2 - Click the Save button to update the Physician/Surgeon Team Table. Repeat as necessary until all Physicians and/or Surgeons are added to the Team Table below. BDCC040_ _FINAL 20

21 Physician/Surgeon Team Table FIRST NAME LAST NAME TYPE 1 NATIONAL PROVIDER IDENTIFIER (NPI) SURGEON OR PHYSICIAN xxx xxx xxx xxx Terms & Conditions A. ATTESTATION Attestation for Provider Survey Participation Blue Distinction Centers for Specialty Care Program(s) By submitting its response to this Provider Survey for consideration as a participant in this Blue Distinction Centers for Specialty Care Program(s) (the Program(s) ), and, if accepted by BCBSA, as a condition to any designation and participation in the Program(s), this provider ( Provider ) represents and agrees as follows: 1. All information that Provider provides in its response to BCBSA's Provider Survey for consideration as a participant in this Program(s) (including information provided in Provider's initial response, as well as any additional materials submitted throughout the evaluation and appeal process for this Provider Survey cycle) is and will be true and complete, as of the date Provider provides such information to BCBSA. Provider will advise BCBSA immediately of any material change in such information during this Provider Survey process, and if Provider is designated as a Blue Distinction Center under this Program(s), for the duration of such designation. 2. BCBSA may share Provider's individual Provider Survey responses ( Raw Data ) and results ( Scores ) with BCBSA's member Plans and, pursuant to a confidentiality agreement, member Plans' current and prospective accounts, for purposes of evaluation, care management, quality improvement, and member Plans' design of customized products and networks. BCBSA may combine Provider's Raw Data and Scores together with other Providers data to create aggregate information for public dissemination, provided that such aggregate information will not identify Provider by name, and will not contain any Protected Health Information ( PHI ), as defined under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (45 C. F. R. Parts ). Provider s Raw Data and Scores will not be publicly disseminated beyond the extent permitted above without Provider's prior written consent, unless required by law (e.g., subpoena). B. OPTIONAL PUBLIC STATEMENT ON HOSPITAL BASED PHYSICIANS PPO STATUS Available Only for Providers that are Hospitals, Ambulatory Surgery Centers and Outpatient Clinics (Not Applicable to Individual Physicians or Physician Groups) These terms apply only if Provider has elected to opt-in to this optional public disclosure feature for this Program. BDCC040_ _FINAL 21

22 Optional Public Statement: BlueCard PPO Network Participation Status of Hospital Based Physicians Provider, at its option, may elect to disclose that all Hospital Based Physicians who provide Related Services at that Provider participate in the Local Plan s BlueCard PPO network (with terms as defined and described below). This feature is not a Program requirement. Provider s decision on whether or not to participate in this feature will not impact its Designation status. If Provider consents to participate in this optional feature for the Program, then Provider represents and warrants voluntarily that, as of the Effective Date of this Agreement, all Hospital Based Physicians who provide Related Services at this Provider participate in the Local Plan s BlueCard PPO network (with terms as defined and described below). With Provider s consent, BCBSA and the Local Plan will convey and recognize this participating physician information through transparent public messaging in the National Doctor & Hospital Finder and other related materials. Provider will provide BCBSA and the Local Plan with at least thirty (30) days prior written notice: (a) if any Hospital Based Physician who may provide Related Services will not participate in the Local Plan s BlueCard PPO network, or (b) if any Hospital Based Physician who does participate in the Local Plan s BlueCard PPO network does not renew its then current participation agreement at least thirty (30) days in advance of its expiration date; and promptly thereafter, BCBSA will remove this public statement from the National Doctor & Hospital Finder and other related materials. BCBSA will provide Provider with notice of opportunities that may arise thereafter to reinstate this public statement, in the event that all Hospital Based Physicians who provide Related Services at this Provider subsequently participate again in the Local Plan s BlueCard PPO network. "Hospital Based Physicians" means all of the following physicians rendering services at this Provider: Radiologists; Anesthesiologists; Pathologists; Hospitalists; and Intensivists. "Related Services" means all services provided by Hospital Based Physicians for adult patients (age 18 years and older) for all episodes of care covered by this Program (as defined at PROVIDER attests that it has read, understands, and agrees with the terms set forth in the Attestation (Section A in the scrolldown box, above) and represents and agrees that the statements therein are accurate. OPTIONAL CHECK IF PROVIDER CONSENTS TO PARTICIPATE IN OPTIONAL PUBLIC STATEMENT FOR THIS BD PROGRAM. PROVIDER has read and understands the Optional Public Statement terms (Section B in the scrolldown box, above) and hereby consents to participate in this optional feature for this Blue Distinction Program, pursuant to the terms set forth therein. Note: Contact BCBSA if this Provider desires to opt in later, or if this Provider opts in now but later needs to opt out of this feature. Provider verifies that it responded to the Attestation and Optional Public Statement items above, by and through its duly authorized officer identified below: Officer s Name: Officer s Title: Date: BDCC040_ _FINAL 22