Participation Agreement for Oregon s Alternative Payment and Care Methodology (APCM)

Transcription

1 Participation Agreement for Oregon s Alternative Payment and Care Methodology (APCM) Between (Health Center) and the Oregon Health Authority (Authority) This agreement shall spell out the terms of participation in Oregon s Alternative Payment and Care Methodology (APCM) program for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). The Program parameters are guided by the Oregon State Plan Amendment Transmittal # 12-08, Attachment 4.19-B; Methods and Standards for Establishing Payment Rates: Alternate Payment Methodology, approved on 9/12/12 by CMS and OAR The intent of the Alternative Payment and Care Methodology (APCM) program is to adjust payment for participating community health centers to allow and encourage the high quality, efficient provision of patient centered health care, incentivizing high value services over a volume of visits. Both parties understand that the program is intended to incent a significant transition in patient centered care, and that it will likely result in a reduction in traditional, billable patient visits. At the same time, we expect that non-billable touches with the patient will increase. Further, both parties acknowledge that as a program, we are committed to working together to address unanticipated challenges and concerns on the part of either party, reaching mutually acceptable solutions. A. Term: This agreement shall be in effect for a minimum of three years starting from July 1, unless terminated by the Health Center under conditions described in Section B. B. Termination: The Health Center reserves the right to terminate their participation in the program if it determines that their participation is threatening the financial viability for the Health Center and efforts between the Authority and Health Center to adjust the model do not resolve the concern. In that instance, the Health Center will give a 30 day notice to OHA in writing. In that instance, the Health Center shall be entitled to payment for all services satisfactorily rendered. C. Minimum Participation Requirements: Participating FQHCs or RHCs agree to participate with all sites within their organization, with all patients receiving covered Oregon Health Plan (OHP) services (as described in Section I), and must have the capacity to meet all reporting requirements referenced in Section M of this agreement. The Health Center is expected to participate in the APCM learning community. D. APCM Rate Calculation: Health Center (with the help of the Oregon Primary Care Association) will work with the Authority to complete a financial and patient member month analysis to compute the Health Center s APCM rates according to the methodology outlined in Attachment A. There will be a wrap cap APCM rate paid for all managed care patients, as well as a full APCM rate paid for open card patients. E. Day One patient list: is defined as the list of patients for which the Health Center will be reimbursed an APCM rate effective the first month of implementation. The list includes OHP eligible patients seen through a paid face to face PPS visit in the prior 18 months at the Health Center, that are attributed to the Health Center after adjusting for eligibility and leakage (patients overlapping with other Health Centers or primary care providers). Health Center is prohibited from using an 18 month look back for an establishing visit after the initial Day One list is loaded through the MMIS Provider Web Portal. After the initial Day One list, Health Center shall use a 12 month look back for an establishing visit. The Authority determines the 12 months based on the date the patient is enrolled with the Health Center through the MMIS Provider Web Portal. F. Engaged Patients: Health Center may add new patients to their APCM roster on the MMIS Provider Web Portal. All new patient enrollments should start on the same date they had the initial (establishing) office visit. The start date for the patient enrollment must be within 12 months of the date Health Center enrolled the patient through the MMIS Provider Web Portal, as outlined in Attachment E. G. Attribution: To prevent the Authority from issuing duplicative primary care payments due to patients receiving services at other primary care providers, the Authority has established an attribution process for when attributed patients access primary care services by outside providers (leakage), as outlined in Attachment D. H. Payment Methodology: The Authority agrees to pay the Health Center its per-member per-month (PMPM) payments each month. Individuals added or deleted from the clinic s patient roster may include a prorated daily PMPM amount. The Authority will send an APM Enrollment Report, including reason codes, for all patient lists uploaded by the Health Center to add or close patients on the APM roster. 1 P a g e

2 I. Rate Adjustment: The APCM rate, once established, will be adjusted annually by the Medicare Economic Index (MEI) in compliance with Federal statute governing the Prospective Payment System (PPS). A Change in Scope (CiS) will be developed that is in concert with the intent and definition of existing CiS regulation for PPS, converting the methodology to a PMPM calculation to align with PMPM APCM rates. Changing the rate assumptions and methodology may only happen by mutual agreement of the health center and OHA and as long as proof of documentation by relevant stakeholders such as the health center, OHA, and OPCA is available. J. Included Services: The APCM rates are per-member per-month rates paid to the Health Center for medical services as defined in the Health Center s established PPS rate calculation (as defined by Federal law). Mental health, dental health and obstetrical services (prenatal and deliveries) are excluded initially from the rate and program, but Health Centers will work with the Authority and OPCA on feasibility and method for including these initially carved out (excluded) services. Once methodology is mutually agreed upon, utilization of these services will be analyzed and the Authority will adjust the per-member per-month APCM rates as needed. K. Open Card and School based health services: Open Card clients are included in the APCM program, and a unique Open Card APCM rate is established. School based health patients and services are also included in the program. L. Quarterly Reconciliation with Annual Adjustment: Health center will complete the quarterly reconciliation comparing revenue earned under the APCM program with revenue that would have been earned under traditional PPS, in accordance with the SPA guidance and Attachment B. This reconciliation is a floor to assure that APCM payment is at least as much as PPS payments would have provided for the same time period. However, Health Centers are not required to return dollars in excess of PPS payments, as determined by the calculation. The Health Centers will be reimbursed by the state for any amount below the PPS payment level based on the state completed Annual Payment Reconciliation. M. Commitment to Produce Data: By signing this agreement the Health Center agrees to produce quarterly data in accordance with Attachment C. Included in the data matrix are goals to get key measures with the Authority and Coordinated Care Organization (CCO) for cost and utilization on a specific timeline, to which the Health Center also commits. After the first year of reporting, the Health Center and Authority will agree to target levels for each indicator. If the Health Center is not meeting said targets for an extended period (3 quarters), the Authority may ask the Health Center to document a performance improvement plan. N. Program development: Both parties agree to work collaboratively to develop acceptable methodology to incorporate additional carved-out services and payments. Both parties agree to work with OPCA to develop a metrics and accountability plan that establishes clear accountability for patient access and financial accountability, as well as goals for quality and total cost improvement. Both parties agree to work collectively to address unintended consequences of program implementation to the satisfaction of both parties, adjusting details of this agreement as needed. Health Center Signature: Date: Authority Signature: Date: 2 P a g e

3 Attachment A: Rate Methodology Worksheet Oregon Primary Care Association APM Development Phase 4 Wrap Cap Data Request Template - health center name For 12 Month Period: MCO Payments Wrap & Reconciliation Payments Total Payments Visits Effective Rates per Visits Patients Visits Visits Per Patient Payments for Managed Care Patients - #DIV/0! 1 Total Less OB payments - #DIV/0! 2 Less Dental Only Less dental payments - #DIV/0! 3 Less Mental Health Only Less mental health payments - #DIV/0! 4 Less OB Only Less CAWEM (non-citizen emergency-only benefit package) - 5 Less Dental/Mental Health/OB Only Less MED (Qualified Medicare Beneficiaries) - 6 Less Full Year Open Card Less OEW payments associated with applicable visits Less Dental/Mental Health/OB Only 7 Open Card Less Other non-pps medicaid paid services 8 Less Partial Year Open Card Patients Less total services not included in PPS rate #DIV/0! Medicaid Managed Care For APM Total Applicable Payments For MCO Patients #DIV/0! Payments for Open Card Patients PPS RATE Less OB payments - Effective Date Less dental payments - Less mental health payments - Less services not included in PPS rate - Total Applicable Open Card Payments #DIV/0! - Total Applicable Payments #DIV/0! "Wrapable" Open Card Calculation MCO portion Portion of Open Card assumed to be MCO "Wrapable" Open Card #DIV/0! #DIV/0! #DIV/0! 3 P a g e

4 Attachment B: Reconciliation Template line Alternative Payment Methodolgy (APM) Reconciliation HIDE THIS COLUMN IF EXPLANATIONS ARE NOT NEEDED For the Period : Include all payments received for services within the period, regardless of when the payment was received 1 PAYMENTS 2 From the State Payments 4 OPEN CARD Client Capitation $ 1, Include all payments received within the reporting period from the State on the weekly 820 file that are for Open Card clients Include all payments received within the reporting period from the State on the weekly 820 file that are associated with Managed Care clients 5 MANAGED CARE Client Wrap Payments 8, Subtotal $ 9, Fee for Service Payments This section EXCLUDES clients who have ONLY Medicare Coverage 8 Cawem, QMB, etc. $ Include payments from DMAP for clients' services not covered on the 820 Include payments received for services that are a carve out from the APM project. Examples are Dental services, services at 9 Carve Outs sites that may not be in the APM Scope, etc. 10 Incorrect claims (MH/OB) Include any other payments received that are not yet recovered by/returned to DMAP 11 Subtotal $ From MCOs/CCOs 14 Capitation Payments $ 4, Include all MEDICAID payments from MCOs / CCOs that are for Capitation 15 Fee for Service Payments 3, Include all MEDICAID Fee for Service payments from MCOs / CCOs 16 Subtotal $ 7, From Medicare / Commercial Payers This section EXCLUDES clients who have ONLY Medicare Coverage but includes all payments for Medi/Medi clients 19 Capitation Payments $ Include all payments from Medicare / Commercial Payers that are for Capitated clients 20 Fee for Service Payments 2, Include all Fee for Service payments from Medicare / Commercial Payersfor clients enrolled in APM 21 Subtotal $ 2, Total Payments $ 20, Total Payments received from all sources Less Payments included above and Received for: 26 From the State Payments 28 Unrecovered 820 Payments $ 5.00 Add here the payments to be excluded for unresolved 820 take backs (if any). Example, deceased clients. 29 Fee for Service Payments 30 Prenatal / OB $ Dental Mental Health Services for Clients NOT enrolled in APM Clinic Sites/Services not in Scope $ From MCOs/CCOs 38 Fee for Service Payments 39 Prenatal / OB $ Dental Mental Health Capitation Paid 43 Services for Clients NOT enrolled in APM Clinic Sites/Services not in Scope $ 1, From Medicare / Commercial Payers 48 Fee for Service Payments Add in this section the payments received for clients excluded from APM. Include Capitation amounts if possible. These are the payments received from DMAP for Prenatal / OB These are the payments received from DMAP for Dental These are the payments received from DMAP for Mental Health These are payments for Clients seen without being established/enrolled; no 820 payments These are the payments received from DMAP for services excluded from PPS to include ineligible benefit plan, services excluded from PPS, etc Add here the payments received for clients excluded from APM. Include Capitation amounts if possible. Add in this section the payments received for clients excluded from APM. Include Capitation amounts if possible. These are the payments received from MCOs / CCOs for Dental These are the payments received from MCOs / CCOs for Mental Health These are the payments received from MCOs / CCOs for clients Not established in APM These are payments for Clients seen without being established/enrolled; no 820 payments These are the payments received from MCOs / CCOs for services excluded from PPS to include ineligible benefit plans Add here the payments received for clients excluded from APM. Include Capitation amounts if possible. 49 Prenatal / OB $ Dental Mental Health Services for Clients NOT enrolled in APM Clinic Sites/Services not in Scope $ Total Excluded Payments $ 2, Sum of Excluded Payments NET Payments for APM Clients (Total Payments less Excuded Payments) $ 18, Total Payments minus Excluded Payments Add in this section the payments received for clients excluded from APM. Include Capitation amounts if possible. These are the payments received from Medicare/Commercial Plans for Dental These are the payments received from Medicare/Commercial Plans for Mental Health These are payments for Clients seen without being established/enrolled; no 820 payments These are the payments received from Medicare/Commercial Plans for services excluded from PPS to include ineligible benefit plans 4 P a g e

5 61 ENCOUNTERS Open Card Mgd.Care 64 Total Medicaid Encounters Less Encounters for: 66 Prenatal / OB Dental Mental Health Clinic Sites not in Scope Encounters for clients NOT on Exclude the encounters for clients that are NOT on the 820. This may include service dates prior to a client being established. 71 CAWEM / QMB 0-5 Exclude here the encounters for clients with non-pps reimburseable Benefit Plans 72 Other (explain) Exclude any other applicable encounters; provide explanation Net APM Encounters Clinic PPS Rate $ Enter the Clinic's PPS rate Total PPS Equivalent Amount $ 3, $ 18, A calculated total of the Net APM Encounters times the Clinic PPS rate Total PPS Equivalent Amount $ 22, A calculated total of the Net APM Encounters times the Clinic PPS rate NET Payments for APM Clients $ 18, The Net APM Payments from above Difference from Actual APM Payments $ 4, APM Settlement Due OTHER INFORMATION 88 Member Months 89 Open Card Clients Managed Care Clients Total Member Months Payments 94 Retroactive payments $ Attribution recoveries (999.00) 96 $ (889.00) The total number of PPS encounters for the period Exclude here the encounters for Prenatal / OB Exclude here the encounters for Dental Exclude here the encounters for Mental Health Exclude here the encounters provided at sites not in Scope (if any) Report the calculated member months for the Open Card clients Report the calculated member months for the Managed Care clients Report the 820 payment amounts received for clients with retroactive coverage, that is payments received in this reporting period that are for previous periods. Report the 820 payment amounts recovered by the State through Attribution, that is payments recovered in this reporting period that are for previous periods. 5 P a g e

6 Attachment C: APCM Metrics and Accountability Plan Oregon APCM Program Metrics and Accountability Plan Purpose: The purpose of this document is to articulate the metrics and accountability strategy for assessing success of the Alternative Payment and Care Model (APCM) Initiative as a partnership with the State of Oregon, the Oregon Primary Care Association and the participating Community Health Centers. Aim of the APCM Initiative as Originally Articulated by OPCA: To prove the value of the freedom from visit based payment by dramatically enhancing the value APCM clinics deliver to a people through improving care of individuals and populations while decreasing total utilization of the health care system. Share Goals: State Medicaid and the Oregon PCA met on June 26, 2014 and confirmed the following shared goals: Progress toward achieving the Triple Aim Ability to demonstrate that the APM and ACM initiatives have had a positive impact Budget neutrality as defined by the same amount paid to the health center per active patient, per year, compared to the rate setting year Ability to clarify the new care model(s) needed in health centers Positive feedback from key stakeholders A basis to justify continuation of the APCM Ideally, this and all health reform initiatives will be looked at for their impact on global costs (as determined by base year plus a 3.4% projected inflation adjustment, in alignment with CMS expectations) Metrics and Accountability Strategy These guidelines will be applied to those APCM established beneficiaries who were enrolled at the beginning and at the end of the program. 1. Track clinically reportable CCO measures plus 5 UDS measures 1 a. Health Centers should choose a minimum of two measures at a time from the list of 9 internal focus measures 2 and 5 UDS measures over the remaining program period horizon and improve or maintain benchmark before continuing to subsequent sets b. One ambulatory utilization measure will be tracked as soon as available c. Sustained or improved patient satisfaction as assessed by CAHPS surveys and/or internal survey 2. The State will track total global costs and success will be considered a maintenance or reduction of per capita costs determined by the prior year base costs adjusted by an increase of 3.4% 3. For established patients who are enrolled at the beginning and end of the study period, a review will done as to how many have had an engagement touch or billable visit in the last 12 months and a stretch target will be established (project to be between 70-75%). An engagement touch will include a portal engagement initiated by 1 Five UDS measures include: Tobacco screening, Childhood immunizations, Weight control: kids and adults, Cervical cancer screening 2 CCO focus measures are defined as measures that are clinically actionable and readily reportable through EHR and claims data. Focus measures include: Alcohol and drug misuse (SBIRT), Depression screening and follow up plan, Follow up for children prescribed ADHD medication, Timeliness of prenatal care, Developmental screenings, Adolescent well care visits, Colorectal cancer screening, Diabetes: HbA1c poor control, Controlling hypertension. 6 P a g e

7 the beneficiary, telephonic contact, or face to face visits. In all cases the engagement will be documented in the electronic health record. The engagement touch will be with a member of the care team (licensed or unlicensed). The definition of engagement touches is in accordance with the list to be finalized in October There will be an ongoing opportunity to reassess the definition of engagement touches. 4. A segmentation tool or methodology will be established by June 2015 that will help inform severity adjustment methods and the care needs of various segments of the beneficiary population 7 P a g e

8 Attachment D: Attribution Policy Attribution Process Reviewed and amended by OPCA, OHA on December 30, Intent and Overview: The Oregon Health Authority (OHA) must prevent duplicate payments from occurring due to APCM enrolled patients receiving services from other primary care providers ( leakage ). To do this, we will monitor all claims for your APCM enrolled patients on a monthly basis, and make APCM enrollment closures when leakage occurs. If your patient s APCM enrollment is end dated because of a visit with a different primary care provider, your health center s re-enrollment date must be after the final leakage date of service on that months Enrollment Change Report (ECR) and the re-enrollment effective date must be the date that your health center reestablishes care with the patient through a billable office visit or TC105. All enrollment changes executed by the OHA will be reported to the APCM organization at least 14 days before the change occurs. All health centers joining the APCM Program will receive a three month grace period where the OHA will not make enrollment changes. The grace period will cover claims DOS during the first three months of APCM participation. The attribution timeline is a rolling six month look-back that shifts forward one month each month. For example, the January 2016 cycle will look at claims dates of service for July December The February 2016 cycle would shift forward to look at claims dates of service between August 2015 and January Here is a sample timeline of one year of attribution for phase 4. Phase 4 Attribution Timeline (Year 1) Attribution Cycle Look-Back DOS Begin Look-Back DOS End Nov-16 10/1/ /31/2016 Dec-16 10/1/ /30/2016 Jan-17 10/1/ /31/2016 Feb-17 10/1/2016 1/31/2017 March-17 10/1/2016 2/29/2017 April-17 10/1/2016 3/31/2017 May-17 11/1/2016 4/30/2017 June-17 12/1/2016 5/31/2017 July-17 1/1/2017 6/30/2017 Aug-17 2/1/2017 7/31/ P a g e Sep-17 3/1/2017 8/31/2017 Oct-17 4/1/2017 9/30/2017

9 Identifying Leakage and End-Dating APCM Enrollments 1. OHA will review primary care claims during the look-back period each month a. At the beginning of each month, the attribution cycle will produce the patients that leaked out to primary care providers in the prior six months (six month look-back period). OHA will determine the type of leakage i. FQHC/RHC/Tribal organizations, OR ii. Other primary care providers 2. FQHC/RHC/Tribal Organization a. APCM patient will be end-dated on the day before the earliest leakage DOS b. Patients with a primary care visit at a different FQHC/RHC/Tribal organization will be end-dated after one visit on the day prior to the DOS 3. Other Primary Care Providers a. Patients receiving primary care services from a different provider (that is not a FQHC/RHC/Tribal Organization) will be end-dated when two or more visits within the lookback period occur b. The end date will be the day before the earliest leakage visit DOS within the six month lookback period Reporting Enrollment Changes to APCM Organizations 1. OHA will document all changes made to an APCM organization s PMPM patient roster 2. Before enrollment changes are completed, the OHA will send the Enrollment Change Report (ECR) through secure to the APCM organization. 3. PMPM payments will be recouped for the timeframe that was removed from the patient s APCM enrollment IF that timeframe had already been paid. 4. PMPM recoupments will be reported on the APCM organization s 820 report and will only recoup from future payments. 5. ECR will indicate: a. Patient s Recipient ID b. Patient s APCM start date and new end date c. The DOS of each visit with a different primary care provider d. Leakage Type: FQHC/RHC/Tribal Organization OR Other Primary Care Provider OR Both Types Restarting PMPM Payments for End-dated APCM Patients 9 P a g e

10 a. The APCM organization can re-enroll the patient with an APM effective date after the final leakage DOS on the ECR AND after a new visit is registered b. The APCM organization shall not re-enroll the APCM patient on a date prior to the final leakage DOS on the ECR c. If sections (a) and (b) are satisfied, the date of re-enrollment should be the date the APCM organization re-established the patient through a billable encounter or Engagement Touch. School Based Health Center Patient Assignment 1. When setting the initial patient list, the APCM organization may enroll all patients encountered at the SBHC 2. A SBHC patient who is assigned to an APCM organization, but who is then seen by another primary care provider will be moved according to the attribution process outlined above 3. NEW engaged patients at the SBHC may be APCM enrolled with your health center according to the same process outlined in the Participation Agreement for all patients. Review Request Process for APCM Enrollment Changes The OHA will consider a division review of an enrollment change when the APCM organization indicates that the alleged leakage visit occurred due to a referral to the other primary care provider, or the leakage visit was a specialty service 1. APCM organization will notify the OHA within 30 days of the ECR send date 2. APCM organization will include the ECR and indicate within the report: a. Recipient ID of referred patient b. Service or condition that caused referral c. Type or specialty of provider patient was referred to d. Name of the provider or organization patient was referred to 3. The OHA will research the alleged leakage visit, and make a final decision within 30 days of receipt of review request Attribution Between APCM Health Centers 1. Patients moved from one APCM health center s list are available for enrollment by a new health center on the day following the end date with the previous APCM health center 2. Functionality is currently available under the eligibility screen on the MMIS Provider Web Portal to view a patient s APCM enrollment status and determine what health center the patient is APCM enrolled with 10 P a g e

11 Attachment E: New Patient Engagement Process APCM Procedure New Patient Engagement Procedure May 13, 2014 Engaged Patients: After establishing the Day One list, the CHC may add patients to their APCM 3131 list as follows: a. By engaging a NEW patient in a traditional billable visit b. By engaging a NEW patient with thorough intake, to include a medical history, problem, medication and allergy review at minimum, will be conducted with a face to face visit with a practitioner as defined in OAR Division Encounter and Recognized Practitioners. This practitioner must be able to assess a patient s health status within the scope of his/her practice. Clinics should be precise in tracking/coding these visits so they are easily reportable. c. Patients who have been seen in the last 12 months at the health center, but who were previously not eligible for OHP may be added to the APCM roster effective the date of service of the establishing visit. PMPM payments will begin on the first day of OHP eligibility. The health center understands that evidence of a visit in the preceding 12 months must be documented in the health center medical record or practice management system. d. Patients who were an engaged patient, but who had lost eligibility may remain on the APCM roster. PMPM payments will only issue for timeframes that the APCM enrolled patient is eligible for OHP. e. All patients will remain engaged and on the APCM roster indefinitely unless and until they are reassigned through the attribution policy, left the area, deceased, or have been dismissed by the Health Center due to threatening or endangering Health Center staff, patients, or other individuals at the facilities. f. Patients removed due to the attribution policy may be added back no sooner than the Final Leakage DOS on the Enrollment Change Report, and after re-establishing care with the patient through methods previously outlined in this attachment Division Encounter and Recognized Practitioners (11) The following practitioners are recognized by the Division: (a) Doctors of medicine, osteopathy and naturopathy; (b) Licensed Physician Assistants; (c) Dentists; (d) Dental Hygienists who hold a Limited Access Permit (LAP) may provide dental hygiene services without the supervision of a dentist in certain settings. For more information, refer to the section on Limited Access Permits, ORS and the appropriate Oregon Board of Dentistry OARs; (e) Pharmacists; (f) Nurse Practitioners; (g) Nurse Midwives; (h) Other specialized nurse practitioners; (i) Registered nurses may accept and implement orders within the scope of their license for client care and treatment under the supervision of a licensed health care professional recognized by the Division in this section and who is authorized to independently diagnose and treat according to appropriate State of Oregon s Board of Nursing OARs; (j) Psychiatrists; (k) Licensed Clinical Social Workers; (l) Clinical psychologists; (m) Acupuncturists Refer to OAR chapter 410, division 130 for service coverage and limitations; (n) Licensed professional counselor; (o) Licensed marriage and family therapist; or 11 P a g e

12 (p) Other health care professionals providing services within their scope of practice and working under the supervision requirements of: (A) Their individual provider s certification or license; or (B) A clinic s mental health certification or alcohol and other drug program approval or licensure by the Addictions and Mental Health Division (AMH) (see OAR ). 12 P a g e

13 Attachment F: Excluded Codes Oregon Alternative Payment and Care Methodology (APCM) Exclusion Agreement for Wrap Cap reimbursement Reviewed and accepted on 5/15/14 by Jamal Furqan at OHA. On March 1, 2013, three Oregon Community Health Centers voluntarily entered into an agreement with the Oregon Health Authority to participate in an Alternative Payment and Care Methodology program to adjust traditional PPS payment for health centers to a capitated equivalent. Each program participant signed a participation agreement with the Health Authority which guides implementation and agreements for the program. Since that date, many further details have evolved in partnership between OPCA, APCM clinics and OHA. This document is intended to outline agreements around services that are excluded from the wrap around capitation, or Wrap Cap, paid by the Oregon Health Authority for each active OHP patient of a program health center. As is noted at the end of the document, the scope of services included in capitation received from the managed care organization may differ, and is guided by the health center s agreement with the MCO or CCO. It is the responsibility of the participating health center to assure that revenue associated with carved out services is excluded from the APCM rate development, and must be documented or included as back up to the clinic s APCM rate worksheet. It is also the responsibility of participating health centers to ensure that submissions for supplemental wraparound only include the encounters and payments for the carved-out services (Dental, Mental Health, Addictions OB, and Maternity Case Management). Policy Agreements: In developing the model on a broad level, the following agreements were reached with respect to included services, and the following language is captured within the MOU: Included Services: The APCM rate is a capitated, per member per month rate paid to the Health Center for Federally Qualified Health Center Services as defined in the Health Center s established PPS rate calculation (and defined by Federal law). Mental health, addictions, dental health, maternity case management, and obstetrical services (prenatal and deliveries) are excluded initially from the rate and program. Open Card: Open Card clients are included in the APCM program, and a unique Open Card APCM rate is established. School based health service: School based health clinic patients and primary care services will be included under wrap cap for those patients. Implementation Agreements: In operationalizing the APCM program, the Oregon Health Authority, OCHIN, OPCA and APCM clinics have worked collaboratively to assure that systems are properly prepared to accept claims and issue payments for those services that are outside of the wrap cap, and to suppress claims for those services that are included within capitation. In developing those systems, a number of more detailed issues have been addressed related to inclusions/exclusions: Scope of Primary Care Services (INCLUDED): Those services included in the primary care PPS rate should be included in the capitation, with the exception of OB/Prenatal excluded codes (Attachment I). OB/Prenatal Care (EXCLUDED): OB/Prenatal Care is excluded from capitation, and must be demonstrated to be excluded from the rate developed for each clinic. The full list of OB/prenatal codes to be excluded are Attachment I. Mental Health and Addictions Services (EXCLUDED): Claims which have a mental health diagnosis code as the primary diagnosis should be excluded. Services provided to a patient with a primary physical health diagnosis, and a secondary mental health diagnosis should NOT be excluded. The list of excluded Mental Health diagnosis codes are Attachment II. 13 P a g e

14 Inpatient Care (EXCLUDED): Inpatient care, with the exception of a newborn visit in the hospital is excluded. Dental Health (EXCLUDED): Dental health services are excluded, including all procedure codes beginning with D. Attachment I: Carved Out OB/Prenatal Care Codes (Approved May 2014 by Jamal Furqan) The following CPT Procedure Codes do not need a Modifier. These codes will pay the PPS encounter rate when they are billed with any appropriate diagnosis. PROCEDURE Modifier Deliveries Codes PROCEDURE Global Codes - Not paid fee-for-service None Vaginal Delivery PRENATAL CARE 7 OR MORE VISITS PKG None Vaginal Delivery Only (w/wo episiotomy &/or forceps) PRENATAL CARE COMPLETE PKG None C/S First assistant VAGINAL DELIVERY ONLY (W/WO EPISIOTOMY &/OR FORCEPS); W/POSTPARTUM CARE None C/S Primary Surgeon ROUTINE OBSTETRIC CARE, ANTEPARTUM CARE, VAGINAL DELIVERY, & POSTPARTUM CARE None Successful VBAC ROUTINE OBSTETRIC CARE W/ANTEPARTUM CARE, CESAREAN DELIVERY, & POSTPARTUM CARE None C/S after attempted VBAC None Surgical Tx for incomplete Ab None Surgical Tx for missed Ab None Surgical Tx for septic Ab None Version None Amniocentesis None Contraction Stress Test None Repair of vaginal lac/epis only None Delivery of Placenta only The following CPT Procedure Codes need to be paired with any diagnosis from this list AND have a Modifier included on the claim to pay at the PPS encounter rate. Procedure Code Modifier Diagnosis O O O O O P a g e

15 99211 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O04.81 O04.82 O04.83 O04.84 O04.85 O P a g e

16 16 P a g e O04.87 O04.88 O04.89 O07.0 O07.1 O07.2 O07.30 O07.31 O07.32 O07.33 O07.34 O07.35 O07.36 O07.37 O07.38 O07.39 O07.4 O08.0 O08.1 O08.2 O08.3 O08.4 O08.5 O08.6 O08.7 O08.81 O08.82 O08.83 O08.89 O08.9 O09.00 O09.01 O09.02 O09.03 O09.10 O09.11 O09.12 O09.13 O O O O O O O O09.299

17 17 P a g e O09.30 O09.31 O09.32 O09.33 O09.40 O09.41 O09.42 O09.43 O O O O O O O O O O O O O O O O O09.70 O09.71 O09.72 O09.73 O O O O O O O O O O O O O09.90 O09.91 O09.92 O09.93 O O10.012

18 18 P a g e O O O10.02 O O O O O10.12 O O O O O10.22 O O O O O10.32 O O O O O10.42 O O O O O10.92 O11.1 O11.2 O11.3 O11.9 O12.00 O12.01 O12.02 O12.03 O12.10 O12.11 O12.12 O12.13 O12.20 O12.21 O12.22 O12.23 O13.1 O13.2

19 19 P a g e O13.3 O13.9 O14.00 O14.02 O14.03 O14.10 O14.12 O14.13 O14.20 O14.22 O14.23 O14.90 O14.92 O14.93 O15.00 O15.02 O15.03 O15.1 O15.9 O16.1 O16.2 O16.3 O16.9 O20.0 O20.8 O20.9 O21.0 O21.1 O21.2 O21.8 O21.9 O22.00 O22.01 O22.02 O22.03 O22.10 O22.11 O22.12 O22.13 O22.20 O22.21 O22.22 O22.23 O22.30 O22.31 O22.32

20 20 P a g e O22.33 O22.40 O22.41 O22.42 O22.43 O22.50 O22.51 O22.52 O22.53 O22.8X1 O22.8X2 O22.8X3 O22.8X9 O22.90 O22.91 O22.92 O22.93 O23.00 O23.01 O23.02 O23.03 O23.10 O23.11 O23.12 O23.13 O23.20 O23.21 O23.22 O23.23 O23.30 O23.31 O23.32 O23.33 O23.40 O23.41 O23.42 O23.43 O O O O O O O O O23.591

21 21 P a g e O O O O23.90 O23.91 O23.92 O23.93 O O O O O24.02 O O O O O24.12 O O O O O24.32 O O O O O O O O O O O24.82 O O O O O24.92 O25.10 O25.11 O25.12 O25.13 O25.2 O26.00 O26.01 O26.02

22 22 P a g e O26.03 O26.10 O26.11 O26.12 O26.13 O26.20 O26.21 O26.22 O26.23 O26.30 O26.31 O26.32 O26.33 O26.40 O26.41 O26.42 O26.43 O26.50 O26.51 O26.52 O26.53 O O O O O26.62 O O O O O26.72 O O O O O O O O O O O O O O O26.843

23 23 P a g e O O O O O O26.86 O O O O O O O O26.90 O26.91 O26.92 O26.93 O28.0 O28.1 O28.2 O28.3 O28.4 O28.5 O28.8 O28.9 O O O O O O O O O O O O O O O O O O O O O29.191

24 24 P a g e O O O O O O O O O O O O29.3X1 O29.3X2 O29.3X3 O29.3X9 O29.40 O29.41 O29.42 O29.43 O29.5X1 O29.5X2 O29.5X3 O29.5X9 O29.60 O29.61 O29.62 O29.63 O29.8X1 O29.8X2 O29.8X3 O29.8X9 O29.90 O29.91 O29.92 O29.93 O O O O O O O O O O O30.023

25 25 P a g e O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O30.801

26 O O O O O O O O O O O O O O O O30.90 O30.91 O30.92 O30.93 O31.00X0 O31.00X1 O31.00X2 O31.00X3 O31.00X4 O31.00X5 O31.00X9 O31.01X0 O31.01X1 O31.01X2 O31.01X3 O31.01X4 O31.01X5 O31.01X9 O31.02X0 O31.02X1 O31.02X2 O31.02X3 O31.02X4 O31.02X5 O31.02X9 O31.03X0 O31.03X1 O31.03X2 O31.03X3 O31.03X4 O31.03X5 26 P a g e

27 27 P a g e O31.03X9 O31.10X0 O31.10X1 O31.10X2 O31.10X3 O31.10X4 O31.10X5 O31.10X9 O31.11X0 O31.11X1 O31.11X2 O31.11X3 O31.11X4 O31.11X5 O31.11X9 O31.12X0 O31.12X1 O31.12X2 O31.12X3 O31.12X4 O31.12X5 O31.12X9 O31.13X0 O31.13X1 O31.13X2 O31.13X3 O31.13X4 O31.13X5 O31.13X9 O31.20X0 O31.20X1 O31.20X2 O31.20X3 O31.20X4 O31.20X5 O31.20X9 O31.21X0 O31.21X1 O31.21X2 O31.21X3 O31.21X4 O31.21X5 O31.21X9 O31.22X0 O31.22X1 O31.22X2

28 28 P a g e O31.22X3 O31.22X4 O31.22X5 O31.22X9 O31.23X0 O31.23X1 O31.23X2 O31.23X3 O31.23X4 O31.23X5 O31.23X9 O31.30X0 O31.30X1 O31.30X2 O31.30X3 O31.30X4 O31.30X5 O31.30X9 O31.31X0 O31.31X1 O31.31X2 O31.31X3 O31.31X4 O31.31X5 O31.31X9 O31.32X0 O31.32X1 O31.32X2 O31.32X3 O31.32X4 O31.32X5 O31.32X9 O31.33X0 O31.33X1 O31.33X2 O31.33X3 O31.33X4 O31.33X5 O31.33X9 O31.8X10 O31.8X11 O31.8X12 O31.8X13 O31.8X14 O31.8X15 O31.8X19

29 29 P a g e O31.8X20 O31.8X21 O31.8X22 O31.8X23 O31.8X24 O31.8X25 O31.8X29 O31.8X30 O31.8X31 O31.8X32 O31.8X33 O31.8X34 O31.8X35 O31.8X39 O31.8X90 O31.8X91 O31.8X92 O31.8X93 O31.8X94 O31.8X95 O31.8X99 O32.0XX0 O32.0XX1 O32.0XX2 O32.0XX3 O32.0XX4 O32.0XX5 O32.0XX9 O32.1XX0 O32.1XX1 O32.1XX2 O32.1XX3 O32.1XX4 O32.1XX5 O32.1XX9 O32.2XX0 O32.2XX1 O32.2XX2 O32.2XX3 O32.2XX4 O32.2XX5 O32.2XX9 O32.3XX0 O32.3XX1 O32.3XX2 O32.3XX3

30 30 P a g e O32.3XX4 O32.3XX5 O32.3XX9 O32.4XX0 O32.4XX1 O32.4XX2 O32.4XX3 O32.4XX4 O32.4XX5 O32.4XX9 O32.6XX0 O32.6XX1 O32.6XX2 O32.6XX3 O32.6XX4 O32.6XX5 O32.6XX9 O32.8XX0 O32.8XX1 O32.8XX2 O32.8XX3 O32.8XX4 O32.8XX5 O32.8XX9 O32.9XX0 O32.9XX1 O32.9XX2 O32.9XX3 O32.9XX4 O32.9XX5 O32.9XX9 O33.0 O33.1 O33.2 O33.3XX0 O33.3XX1 O33.3XX2 O33.3XX3 O33.3XX4 O33.3XX5 O33.3XX9 O33.4XX0 O33.4XX1 O33.4XX2 O33.4XX3 O33.4XX4

31 31 P a g e O33.4XX5 O33.4XX9 O33.5XX0 O33.5XX1 O33.5XX2 O33.5XX3 O33.5XX4 O33.5XX5 O33.5XX9 O33.6XX0 O33.6XX1 O33.6XX2 O33.6XX3 O33.6XX4 O33.6XX5 O33.6XX9 O33.7 O33.8 O33.9 O34.00 O34.01 O34.02 O34.03 O34.10 O34.11 O34.12 O34.13 O34.21 O34.29 O34.30 O34.31 O34.32 O34.33 O34.40 O34.41 O34.42 O34.43 O O O O O O O O O34.531

32 O O O O O O O O34.60 O34.61 O34.62 O34.63 O34.70 O34.71 O34.72 O34.73 O34.80 O34.81 O34.82 O34.83 O34.90 O34.91 O34.92 O34.93 O35.0XX0 O35.0XX1 O35.0XX2 O35.0XX3 O35.0XX4 O35.0XX5 O35.0XX9 O35.1XX0 O35.1XX1 O35.1XX2 O35.1XX3 O35.1XX4 O35.1XX5 O35.1XX9 O35.2XX0 O35.2XX1 O35.2XX2 O35.2XX3 O35.2XX4 O35.2XX5 O35.2XX9 O35.3XX0 O35.3XX1 32 P a g e

33 33 P a g e O35.3XX2 O35.3XX3 O35.3XX4 O35.3XX5 O35.3XX9 O35.4XX0 O35.4XX1 O35.4XX2 O35.4XX3 O35.4XX4 O35.4XX5 O35.4XX9 O35.5XX0 O35.5XX1 O35.5XX2 O35.5XX3 O35.5XX4 O35.5XX5 O35.5XX9 O35.6XX0 O35.6XX1 O35.6XX2 O35.6XX3 O35.6XX4 O35.6XX5 O35.6XX9 O35.7XX0 O35.7XX1 O35.7XX2 O35.7XX3 O35.7XX4 O35.7XX5 O35.7XX9 O35.8XX0 O35.8XX1 O35.8XX2 O35.8XX3 O35.8XX4 O35.8XX5 O35.8XX9 O35.9XX0 O35.9XX1 O35.9XX2 O35.9XX3 O35.9XX4 O35.9XX5

34 34 P a g e O35.9XX9 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

35 35 P a g e O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

36 O O O O O O O O O O O O O O O O O O O O O O36.20X0 O36.20X1 O36.20X2 O36.20X3 O36.20X4 O36.20X5 O36.20X9 O36.21X0 O36.21X1 O36.21X2 O36.21X3 O36.21X4 O36.21X5 O36.21X9 O36.22X0 O36.22X1 O36.22X2 O36.22X3 O36.22X4 O36.22X5 O36.22X9 O36.23X0 O36.23X1 O36.23X2 O36.23X3 36 P a g e

37 37 P a g e O36.23X4 O36.23X5 O36.23X9 O36.4XX0 O36.4XX1 O36.4XX2 O36.4XX3 O36.4XX4 O36.4XX5 O36.4XX9 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

38 O O O O O O O O O O O O O O O O O O O O O36.60X0 O36.60X1 O36.60X2 O36.60X3 O36.60X4 O36.60X5 O36.60X9 O36.61X0 O36.61X1 O36.61X2 O36.61X3 O36.61X4 O36.61X5 O36.61X9 O36.62X0 O36.62X1 O36.62X2 O36.62X3 O36.62X4 O36.62X5 O36.62X9 O36.63X0 O36.63X1 O36.63X2 O36.63X3 O36.63X4 38 P a g e

39 39 P a g e O36.63X5 O36.63X9 O36.70X0 O36.70X1 O36.70X2 O36.70X3 O36.70X4 O36.70X5 O36.70X9 O36.71X0 O36.71X1 O36.71X2 O36.71X3 O36.71X4 O36.71X5 O36.71X9 O36.72X0 O36.72X1 O36.72X2 O36.72X3 O36.72X4 O36.72X5 O36.72X9 O36.73X0 O36.73X1 O36.73X2 O36.73X3 O36.73X4 O36.73X5 O36.73X9 O36.80X0 O36.80X1 O36.80X2 O36.80X3 O36.80X4 O36.80X5 O36.80X9 O O O O O O O O O

40 40 P a g e O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

41 O O O O O O O O O O O O O O O O O O O O O O O36.90X0 O36.90X1 O36.90X2 O36.90X3 O36.90X4 O36.90X5 O36.90X9 O36.91X0 O36.91X1 O36.91X2 O36.91X3 O36.91X4 O36.91X5 O36.91X9 O36.92X0 O36.92X1 O36.92X2 O36.92X3 O36.92X4 O36.92X5 O36.92X9 O36.93X0 O36.93X1 O36.93X2 41 P a g e

42 42 P a g e O36.93X3 O36.93X4 O36.93X5 O36.93X9 O40.1XX0 O40.1XX1 O40.1XX2 O40.1XX3 O40.1XX4 O40.1XX5 O40.1XX9 O40.2XX0 O40.2XX1 O40.2XX2 O40.2XX3 O40.2XX4 O40.2XX5 O40.2XX9 O40.3XX0 O40.3XX1 O40.3XX2 O40.3XX3 O40.3XX4 O40.3XX5 O40.3XX9 O40.9XX0 O40.9XX1 O40.9XX2 O40.9XX3 O40.9XX4 O40.9XX5 O40.9XX9 O41.00X0 O41.00X1 O41.00X2 O41.00X3 O41.00X4 O41.00X5 O41.00X9 O41.01X0 O41.01X1 O41.01X2 O41.01X3 O41.01X4 O41.01X5 O41.01X9

43 43 P a g e O41.02X0 O41.02X1 O41.02X2 O41.02X3 O41.02X4 O41.02X5 O41.02X9 O41.03X0 O41.03X1 O41.03X2 O41.03X3 O41.03X4 O41.03X5 O41.03X9 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

44 44 P a g e O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

45 O O O O O O O41.8X10 O41.8X11 O41.8X12 O41.8X13 O41.8X14 O41.8X15 O41.8X19 O41.8X20 O41.8X21 O41.8X22 O41.8X23 O41.8X24 O41.8X25 O41.8X29 O41.8X30 O41.8X31 O41.8X32 O41.8X33 O41.8X34 O41.8X35 O41.8X39 O41.8X90 O41.8X91 O41.8X92 O41.8X93 O41.8X94 O41.8X95 O41.8X99 O41.90X0 O41.90X1 O41.90X2 O41.90X3 O41.90X4 O41.90X5 O41.90X9 O41.91X0 O41.91X1 O41.91X2 O41.91X3 O41.91X4 45 P a g e

46 46 P a g e O41.91X5 O41.91X9 O41.92X0 O41.92X1 O41.92X2 O41.92X3 O41.92X4 O41.92X5 O41.92X9 O41.93X0 O41.93X1 O41.93X2 O41.93X3 O41.93X4 O41.93X5 O41.93X9 O42.00 O O O O O42.02 O42.10 O O O O O42.12 O42.90 O O O O O42.92 O O O O O O O O O O O O43.109

47 47 P a g e O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O43.90 O43.91 O43.92 O43.93 O44.00 O44.01 O44.02 O44.03 O44.10 O44.11 O44.12 O44.13 O O45.002

48 48 P a g e O O O O O O O O O O O O O O O45.8X1 O45.8X2 O45.8X3 O45.8X9 O45.90 O45.91 O45.92 O45.93 O O O O O O O O O O O O O O O O O46.8X1 O46.8X2 O46.8X3 O46.8X9 O46.90 O46.91 O46.92 O46.93

49 O47.00 O47.02 O47.03 O47.1 O47.9 O48.0 O48.1 O60.00 O60.02 O60.03 O60.10X0 O60.10X1 O60.10X2 O60.10X3 O60.10X4 O60.10X5 O60.10X9 O60.12X0 O60.12X1 O60.12X2 O60.12X3 O60.12X4 O60.12X5 O60.12X9 O60.13X0 O60.13X1 O60.13X2 O60.13X3 O60.13X4 O60.13X5 O60.13X9 O60.14X0 O60.14X1 O60.14X2 O60.14X3 O60.14X4 O60.14X5 O60.14X9 O60.20X0 O60.20X1 O60.20X2 O60.20X3 O60.20X4 O60.20X5 O60.20X9 O60.22X0 49 P a g e

50 O60.22X1 O60.22X2 O60.22X3 O60.22X4 O60.22X5 O60.22X9 O60.23X0 O60.23X1 O60.23X2 O60.23X3 O60.23X4 O60.23X5 O60.23X9 O61.0 O61.1 O61.8 O61.9 O62.0 O62.1 O62.2 O62.3 O62.4 O62.8 O62.9 O63.0 O63.1 O63.2 O63.9 O64.0XX0 O64.0XX1 O64.0XX2 O64.0XX3 O64.0XX4 O64.0XX5 O64.0XX9 O64.1XX0 O64.1XX1 O64.1XX2 O64.1XX3 O64.1XX4 O64.1XX5 O64.1XX9 O64.2XX0 O64.2XX1 O64.2XX2 O64.2XX3 50 P a g e

51 51 P a g e O64.2XX4 O64.2XX5 O64.2XX9 O64.3XX0 O64.3XX1 O64.3XX2 O64.3XX3 O64.3XX4 O64.3XX5 O64.3XX9 O64.4XX0 O64.4XX1 O64.4XX2 O64.4XX3 O64.4XX4 O64.4XX5 O64.4XX9 O64.5XX0 O64.5XX1 O64.5XX2 O64.5XX3 O64.5XX4 O64.5XX5 O64.5XX9 O64.8XX0 O64.8XX1 O64.8XX2 O64.8XX3 O64.8XX4 O64.8XX5 O64.8XX9 O64.9XX0 O64.9XX1 O64.9XX2 O64.9XX3 O64.9XX4 O64.9XX5 O64.9XX9 O65.0 O65.1 O65.2 O65.3 O65.4 O65.5 O65.8 O65.9