HEDIS Resource Guide Behavioral Health

HEDIS Resource Guide Behavioral Health NA8PROGDE04232E_0000

What s Inside 1 What is HEDIS? 2 HEDIS Reference Guide for Behavioral Health 14 Behavioral Health HEDIS Measures

What Is HEDIS? The Healthcare Effectiveness Data and Information Set (HEDIS) of performance measures is utilized by more than 90 percent of America's health plans. The performance measure rates generated, using the HEDIS measures' specifications, allow health plans to compare how well they perform to other health plans in the following areas: Quality of care Access to care Member satisfaction with the health plan and doctors Why HEDIS Is Important HEDIS is a tool used by health plans to measure performance of health plans by consumers and employers. Value of HEDIS to You, Our Providers When linked with HEDIS quality data, RRU measures help members, plans, employers, benefit managers and other interested groups, make informed choices about health care services. HEDIS can also help you: Identify noncompliant members to ensure they receive appropriate treatment and follow-up care Understand how you compare with other WellCare providers as well as with the national average Value of HEDIS to Your Patients, Our Members HEDIS gives members the ability to review and compare plans scores, helping them to make informed health care choices. What You Can Do Encourage your patients to schedule health care visits and required metabolic testing Remind your patients to follow up with ordered tests Complete outreach calls to noncompliant members If you have questions about HEDIS or need more information, please contact your local Provider Relations representative or Quality Practice Advisor (QPA). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: www.ncqa.org 2018 Behavioral Health Resource Guide 1

HEDIS Reference Guide for Behavioral Health The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in compliance with the HEDIS 2018 Volume 2 Technical Specifications. Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement. ICD-10 codes must be used effective Oct. 1, 2015. ICD-9 codes are included for certain measures because they remain in effect for the HEDIS 2018 technical specifications. Transitions of Care (TRC) First-Year Measure Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year. Four rates are reported: Notification of Inpatient Admission: Documentation of receipt of notification of inpatient admission on the day of admission or the following day. Receipt of Discharge Information: Documentation of receipt of discharge information on the day of discharge or the following day. Patient Engagement After Inpatient Discharge: Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. Medication Reconciliation Post-Discharge: Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days). CPT HCPCS 99201-99205, 99211-99215,99241-99245, 99341-99345, 99347- G0402, G0438, G0439, G0463, T1015 99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456 TCM 7 Day: 99496 TCM 14 Day: 99495 Medical Reconciliation: CPT: 99495,99496 CPT II: 1111F Telephone Visits: 98966-98968,99441-99443 Telehealth Modifier: 95, GT Antidepressant Medication Management (AMM) The percentage of members 18 years of age and older with a diagnosis of major depression, were treated with antidepressant medication and remained on an antidepressant medication treatment. Two rates are reported. 1. Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). 2. Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). Code set ICD-9-CM Diagnosis 296.20-296.25, 296.30-296.35, 298.0, 311 ICD-10-CM Diagnosis F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 CPT HCPCS AMM Stand Alone Visits: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99510 ED Visits: 99281-99285 Telephone Visits: 98966-98968, 99441-99443 Telehealth Modifier: 95, GT CPT AMM Visits: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876, 99221-99223, 99231-99233, 99238, 99239, 99251-99255 AMM Stand Alone Visits: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 WITH POS AMM Visits: 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 2018 Behavioral Health Resource Guide 2

Antidepressant Medications: The following list of medications is based upon the 2018 HEDIS Technical Specifications. Please reference the State Formulary for covered medications. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. For Medicare, please refer to the WellCare Formulary. Description Prescription Miscellaneous Bupropion Vilazodone Vortioxetine Antidepressants Monoamine Oxidase Inhibitors Phenylpiperazine Antidepressants Psychotherapeutic Combinations SNRI Antidepressants SSRI Antidepressants Tetracyclic Antidepressants Tricyclic Antidepressants Isocarboxazid Phenelzine Nefazodone Selegiline Tranylcypromine Trazodone Amitriptyline-chlordiazepoxide Amitriptyline-perphenazine Fluoxetine-olanzapine Desvenlafaxine Duloxetine Citalopram Escitalopram Maprotiline Amitriptyline Amoxapine Clomipramine Levomilnacipran Venlafaxine Fluoxetine Fluvoxamine Mirtazapine Desipramine Doxepin (>6mg) Imipramine Follow-Up After Hospitalization for Mental Illness (FUH) Paroxetine Sertraline Nortriptyline Protriptyline Trimipramine The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses, and who had a follow-up visit with a mental health practitioner. Two rates are reported: The percentage of discharges for which the member received follow-up within 7 days of discharge. The percentage of discharges for which the member received follow-up within 30 days of discharge. Does not include visits that occur on the date of discharge. Code set An MD or doctor of osteopathy (DO) who is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry and is licensed to practice patient care psychiatry or child psychiatry, if required by the state of practice. An individual who is licensed as a psychologist in his/her state of practice, if required by the state of practice. An individual who is certified in clinical social work by the American Board of Examiners, who is listed on the National Association of Social Worker s Clinical Register, or who has a master s degree in social work and is licensed or certified to practice as a social worker, if required by the state of practice. A registered nurse (RN) who is certified by the American Nurses Credentialing Center (a subsidiary of Mental Health Practitioner the American Nurses Association) as a psychiatric nurse or mental health clinical nurse specialist, or who has a master s degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical experience, and is licensed to practice as a psychiatric or mental health nurse, if required by the state of practice. An individual (normally with a master s or a doctoral degree in marital and family therapy and at least two years of supervised clinical experience) who is practicing as a marital and family therapist and is licensed or a certified counselor by the state of practice, or if licensure or certification is not required by the state of practice, who is eligible for clinical membership in the American Association for Marriage and Family Therapy. An individual (normally with a master s or doctoral degree in counseling and at least two years of supervised clinical experience) who is practicing as a professional counselor and who is licensed or certified to do so by the state of practice, or if licensure or certification is not required by the state of practice, is a National Certified Counselor with a Specialty Certification in Clinical Mental Health Counseling from the National Board for Certified Counselors (NBCC). 2018 Behavioral Health Resource Guide 3

295.00-299.91, 300.3, 300.4, 301.0, 301.10-301.13, 301.20-301.22, 301.3, 301.4, 301.50-301.59, 301.6, 301.7, 301.81- ICD-9-CM Diagnosis 301.89, 301.9, 308.0-308.9, 309.0, 309.1, 309.21-309.29, 309.3, 309.4, 309.81-309.89, 309.9, 311, 312.00-314.9 ICD-10-CM Diagnosis Use the appropriate code family: F CPT HCPCS Follow-up visits identified by the following CPT or HCPCS codes must be with a mental health practitioner within 7 and 30 days of discharge. Stand Alone Visits: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510 Transitional Care: 99495 (14 Days, used for 30-Day Follow-up indicator) and 99496 (7 Days) Telehealth Modifiers: 95, GT CPT G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 POS Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner. 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 WITH 90853, 90867-90870, 90875, 90876 99221-99223, 99231-99233, 99238, 99239, 99251-99255 WITH 52, 53 Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET) The percentage of adolescent and adult members (ages 13 and older, Jan. 1 Nov. 14) with a new episode of alcohol or other drug (AOD) abuse or dependence who received the following: Initiation of AOD Treatment: The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication assisted treatment (MAT) within 14 days of the diagnosis. Engagement of AOD Treatment: The percentage of members who initiated treatment, and who had two or more additional AOD services or MAT within 34 days of the initiation visit. For ED visits resulting in an inpatient stay, an AOD diagnosis is not required for the stay when identifying the IESD. Code set AOD: 291.0-291.5, 291.81-291.89, 291.9, 303.00-303.02, 303.90, 303.91, 303.92, 304.00-304.02, 304.10-304.12, 304.20-304.22, 304.30-304.32, 304.40-304.42, 304.50-304.52, 304.60-304.62, 304.70-304.72, 304.80-304.82, ICD-9-CM Diagnosis 304.90-304.92, 305.00-305.02, 305.20-305.22, 305.30-305.32, 305.40-305.42, 305.50-305.52, 305.60-305.62, 305.70-305.72, 305.80-305.82, 305.90-305.92, 535.30, 535.31, 571.1 ICD-10-CM Diagnosis Use the appropriate code family: F CPT HCPCS Stand Alone Visits identified by the following CPT or HCPCS combined with AOD Diagnosis Code 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99408, 99409, 99411, 99412, 99510 Telephone Visits: 98966-98968, 99441-99443 Telehealth Modifiers: 95, GT Online Assessment: 98969, 99444 CPT IET visits identified by the following CPT/POS codes combined with AOD Diagnosis Code 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876 G0155, G0176, G0177, G0396, G0397, G0409-G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 WITH 99221-99223, 99231-99233, 99238, 99239, 99251-99255 WITH 52, 53 POS 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 2018 Behavioral Health Resource Guide 4

Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA): MEDICAID ONLY The percentage of members ages 19-64 during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, ICD-9-CM Diagnosis 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95 ICD-10-CM Diagnosis F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 14-day supply: J2794 HCPCS 28-day supply: J0401, J1631, J2358, J2426, J2680 Oral Antipsychotic Medications: For a complete list of medications and NDC codes, please visit www.ncqa.org. The following list is based upon 2018 HEDIS Technical Specifications; please reference the State Formulary for covered medications. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription Days Supply Miscellaneous antipsychotic agents (oral) Phenothiazine antipsychotics (oral) Psychotherapeutic combinations (oral) Thioxanthenes (oral) Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Chlorpromazine Fluphenazine Amitriptylineperphenazine Thiothixene Aripiprazole Fluphenazine decanoate Risperidone Haloperidol Iloperidone Loxapine Lurisadone Molindone Olanzapine Perphenazine Prochlorperazine Fluoxetineolanzapine Haloperidol decanoate Olanzapine Paliperidone Pimozide Quetiapine Quetiapine fumarate Risperidone Ziprasidone Thioridazine Trifluoperazine Paliperidone palmitate Exclusions include members who met at least one of the following during the measurement year: 1) Dementia diagnosis 2) Did not receive at least two (2) antipsychotic medication dispensing events ICD-9-CM Diagnosis ICD-10-CM Diagnosis 28-day supply 14-day supply 290.0, 290.10-290.13, 290.20, 290.21, 290.3, 290.40-290.43, 290.8, 290.9, 291.2, 292.82, 294.0, 294.10, 294.11, 294.20, 294.21, 331.0, 331.82 Use the appropriate code family: F, G Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD): MEDICAID ONLY Percentage of members ages 18-64 with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test. Schizophrenia: 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95 ICD-9-CM Diagnosis Bipolar Disorder: 296.00-296.06, 296.10-296.16, 296.40-296.46, 296.50-296.56, 296.60-296.66, 296.7 Other Bipolar Disorders: 296.80-296.82, 296.89 Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Bipolar Disorder: F30.10-F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, ICD-10-CM Diagnosis F31.60-F31.64, F31.70-F31.78 Other Bipolar Disorders: F31.81, F31.89, F31.9 CPT 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951, 83036, 83037 CPT II 3044F, 3045F, 3046F 2018 Behavioral Health Resource Guide 5

Antipsychotic Medications: For a complete list of medications and NDC codes, please visit www.ncqa.org. The following list is based upon 2018 HEDIS Technical Specifications; please reference the State Formulary for covered medications. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Chlorpromazine Fluphenazine Thiothixene Aripiprazole Long-acting injections Fluphenazine decanoate Haloperidol decanoate Antipsychotic Combination Medications Psychotherapeutic Fluoxetine-olanzapine combinations Haloperidol Iloperidone Loxapine Lurisadone Molindone Perphenazine Prochlorperazine Olanzapine Paliperidone Pimozide Quetiapine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Risperidone Perphenazine-amitriptyline Quetiapine fumarate Risperidone Ziprasidone Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD): MEDICAID ONLY The percentage of members ages 18-64 with schizophrenia and diabetes who had both an LDL-C and an HbA1c test during the measurement year. ICD-9-CM Diagnosis ICD-10-CM Diagnosis CPT CPT II Schizophrenia: 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95 Diabetes: 250.00-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63, 250.70-250.73, 250.80-250.83, 250.90-250.93, 357.2, 362.01-362.07, 366.41, 648.00-648.04 Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Diabetes: Use the appropriate code family: E or O (pre-existing DM in pregnancy) HbA1c tests: 83036, 83037 LDL-C tests: 80061, 83700, 83701, 83704, 83721 3044F, 3045F, 3046F, 3048F, 3049F, 3050F Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC): MEDICAID ONLY The percentage of members 18 64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year. Schizophrenia: 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95 Ischemic Vascular Disease (IVD): 411.0, 411.1, 411.81, 411.89, 413.0, 413.9, 414.00-414.07, 414.2-414.4, 414.8, 414.9, ICD-9-CM Diagnosis 429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80, 433.81, 433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91, 437.0, 440.0, 440.1, 440.20-440.24, 440.29-440.32, 440.4, 440.8, 440.9, 444.01, 444.09, 444.1, 444.21, 444.22, 444.81, 444.89, 444.9, 445.01, 445.02, 445.81, 445.89 Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 ICD-10-CM Diagnosis Ischemic Vascular Disease (IVD): Use the appropriate code family: I CPT Code Set LDL-C Test 80061, 83700, 83701, 83704, 83721 CPT II 3048F, 3049F, 3050F 2018 Behavioral Health Resource Guide 6

Follow-Up Care for Children Prescribed ADHD Medication (ADD): MEDICAID ONLY The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported: Initiation Phase. The percentage of members 6-12 years of age as of the Index Prescription Start Date (IPSD) with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase. The percentage of members 6-12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after Initiation Phase ended. One of the two visits (during the 31-300) may be a telephone or telehealth visit with any practitioner. CPT Code Set Stand Alone Visits: 96150-96154, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99384, 99391-99394, 99401-99404, 99411, 99412, 99510 CPT codes Telephone Visits: 98966-98968, 99441-99443 Telehealth Modifiers: 95, GT G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, HCPCS H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 CPT POS Outpatient, intensive outpatient or partial hospitalization visits identified by the following CPT/POS codes must be with a practitioner with prescribing authority. 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 71, 72 WITH 90849, 90853, 90875, 90876 99221-99223, 99231-99233, 99238, 99239, 99251-99255 WITH 52, 53 ADHD Medications: The following list of medications is based upon the 2018 HEDIS Tech Specs. For a complete list, visit www.ncqa.org. Please reference the State Formulary to see if a medication is covered. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription CNS stimulants Amphetamine-dextroamphetamine Dexmethylphenidate Dextroamphetamine 2018 Behavioral Health Resource Guide 7 Lisdexamfetamine Methamphetamine Methylphenidate Alpha-2 receptor agonists Clonidine Guanfacine Miscellaneous ADHD Atomoxetine medications Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC): MEDICAID ONLY The percentage of children and adolescents ages 1 17 who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. (Note: A lower rate indicates better performance.) Antipsychotic Medications: For a complete list of medications and NDC codes, please visit www.ncqa.org. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Chlorpromazine Fluphenazine Perphenazine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol Iloperidone Loxapine Lurisadone Perphenazineamitriptyline Prochlorperazine Haloperidol decanoate Olanzapine Molindone Olanzapine Paliperidone Pimozide Thioridazine Trifluoperazine Paliperidone palmitate Risperidone Quetiapine Quetiapine fumarate Risperidone Ziprasidone

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM): MEDICAID ONLY The percentage of children and adolescents 1 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing during the measurement year. CPT Code Set Cholesterol Tests Other Than LDL Glucose Tests HbA1c Tests LDL-C Tests 82465, 83718, 84478 LIONC: 2085-9, 2093-3, 2571-8, 5932-9 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951 LOINC: 10450-5, 14753-8, 14754-6, 14756-1, 14757-9, 14759-5, 14764-5, 14765-2, 14771-0, 1492-8, 1494-4, 1496-9, 1499-3, 14995-5, 1501-6, 1504-0, 1507-3, 1514-9, 1518-8, 1530-5, 1533-9, 1554-5, 1557-8, 1558-6, 17865-7, 20436-2, 20437-0, 20438-8, 25666-9, 26554-6, 30251-3, 30265-3, 30267-9, 32320-4, 40285-9, 40286-7, 41024-1, 49134-0, 51597-3, 55351-1, 55381-8, 6749-6, 74774-1, 9375-7 83036, 83037, 3044F, 3045F, 3046F LIONC: 17856-6, 4548-4, 4549-2 80061, 83700, 83701, 83704, 83721, 3048F, 3049F, 3050F LIONC: 12773-8, 13457-7, 18261-8, 18262-6, 2089-1, 49132-4, 55440-2 Antipsychotic Medications: For a complete list of medications and NDC codes, please visit www.ncqa.org. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Chlorpromazine Fluphenazine Perphenazine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate Antipsychotic Comination Medications Description Prescription Psychotherapeutic combinations Fluoxetine-olanzapine Perphenazine-amitriptyline Iloperidone Loxapine Lurisadone Molindone Olanzapine Paliperidone Prochlorperazine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Risperidone 2018 Behavioral Health Resource Guide 8 Pimozide Quetiapine Quetiapine fumarate Risperidone Ziprasidone Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP): MEDICAID ONLY The percentage of children and adolescents 1 17 years of age who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment. Documentation of psychosocial care with or without a telehealth modifier in the 121-day period from 90 days prior to the IPSD through 30 days after the IPSD. Psychosocial Care Code set ICD-9-CM Diagnosis Schizophrenia: 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95 Bipolar Disorder: 296.00-296.06, 296.10-296.16, 296.40-296.46, 296.50-296.56, 296.60-296.66, 296.7 ICD-10-CM Diagnosis Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Bipolar Disorder: F30.10-F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78 Other Psychotic Disorders: F22, F23, F24, F28, F29, F32.3, F33.3, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F95.0, F95.1, F95.2, F95.8, F95.9

CPT Codes Psychosocial Care: 90832-90834, 90836-90840, 90845-90847, 90849, 90853, 90875, 90876, 90880 Telehealth Visits: 98966-98968, 99441-99443 Telehealth Modifier: 95, GT HCPCS Codes Psychosocial Care: G0176, G0177, G0409-G0411, H0004, H0035-H0040, H2000, H2001, H2011-H2014, H2018-H2020, S0201, S9480, S9484, S9485 Antipsychotic Medications: For a complete list of medications and NDC codes, please visit www.ncqa.org. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. Description Prescription Miscellaneous antipsychotic agents Phenothiazine antipsychotics Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Chlorpromazine Fluphenazine Perphenazine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate Antipsychotic Comination Medications Description Prescription Psychotherapeutic combinations Fluoxetine-olanzapine Perphenazine-amitriptyline Iloperidone Loxapine Lurisadone Molindone Olanzapine Paliperidone Prochlorperazine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Risperidone Pimozide Quetiapine Quetiapine fumarate Risperidone Ziprasidone 2018 Behavioral Health Resource Guide 9

Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS) The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia, and who had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. (Administered PHQ-9 tool at least once during a four-month period.) Two rates are reported: 1. ECDS Coverage: The percentage of members 12 and older with a diagnosis of major depression or dysthymia, for whom a health plan can receive any electronic clinical data system (ECDS). 2. Utilization of PHQ-9 Rate: The percentage of PHQ-9 utilization. Members with a diagnosis of major depression or dysthymia whose measure data are reportable using ECDS and had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. Selection of the appropriate assessment should be based on the age of the member. 1. PHQ-9: For 13 years of age and above. 2. PHQ-9 Modified for Teens: For ages 12 18. The PHQ-9 assessment does not need to occur during a face-to-face encounter. For example, it can be completed over the telephone or through a Web-based portal. Clinical Recommendation Statement Standardized instruments are useful in identifying meaningful change in clinical outcomes over time. Guidelines for adults recommend that providers establish and maintain regular follow-up with patients diagnosed with depression and use a standardized tool to track symptoms. 9 For adolescents, guidelines recommend systematic and regular tracking of treatment goals and outcomes, including assessing depressive symptoms. 10 The PHQ-9 tool assesses the nine DSM, Fourth Edition, Text Revision (DSM-IV-TR) criterion symptoms and effects on functioning, and has been shown to be highly accurate in discriminating patients with persistent major depression, partial remission and full remission. 9 Trangle, M., J. Gursky, R. Haight, J. Hardwig, T. Hinnenkamp, D. Kessler, N. Mack, M. Myszkowski. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016. 10 Cheung, A.H., R.A. Zuckerbrot, P.S. Jensen, K. Ghalib, D. Laraque, R.E.K. Stein. 2007. GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and Ongoing management. Pediatrics 120(5):e1313 26. ICD-9-CM Diagnosis Major Depression and Dysthymia: 296.20-296.26, 296.30-296.36, 300.4 ICD-10-CM Diagnosis Major Depression and Dysthymia: F32.0-5, F32.9, F33.0-3, F33.40-42, F33.9, F34.1 Interactive Outpatient Encounter: 90791, 90792, 90832, 90834, 90837, 98960-98962, 99078, 99201- CPT 99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99510 Interactive Outpatient Encounter: G0155, G0176, G0177, G0409-G0411, G0463, G0502, G0503, G0507, HCPCS H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 LOINC PHQ Administered: 44249-1, 44257-4, 44261-6, 54635-8 Depression Remission or Response for Adolescents and Adults (DRR) 12 years and older with a diagnosis of depression and an elevated PHQ-9 score who had evidence of response or remission within 4-8 months of the elevated score. Four rates are reported: ECDS Coverage: Members for whom a health plan can receive any electronic clinical quality data. Follow-Up PHQ-9: The percentage of members who have a follow-up PHQ-9 score documented within the four to eight months after the initial elevated PHQ-9 score. Depression Remission: The percentage of members who achieved remission within 4 to 8 months after the initial elevated PHQ-9 score. Members who achieve remission of depression symptoms as noted by a PHQ-9 depression response score of <5 recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded. Depression Response: The percentage of members who showed response within 4 to 8 months after the initial elevated PHQ-9 score. Members who indicate a response to depression treatment as noted by a PHQ-9 depression response score at least 50% lower than the PHQ-9 score associated with the Index Episode Start Date (IESD), recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded. The PHQ-9 assessment does not need to occur during a face-to-face encounter. For example, it can be completed over the telephone or through a Web-based portal. ICD-9-CM Diagnosis Major Depression and Dysthymia: 296.20-296.26, 296.30-296.36, 300.4 ICD-10-CM Diagnosis Major Depression and Dysthymia: Use the appropriate code family: F 2018 Behavioral Health Resource Guide 10

Depression Encounter: 90791, 90792, 90832, 90834, 90837, 98960-98962, 99078, 99201-99205, CPT 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99510 Depression Encounter: G0155, G0176, G0177, G0409-G0411, G0463, G0502, G0503, G0507, H0002, HCPCS H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 LOINC PHQ Administered: 44249-1, 44257-4, 44261-6, 54635-8 Follow-Up After Emergency Department Visit for Mental Illness (FUM) The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness, and who had a follow-up visit for mental illness. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. 290.0, 290.10-290.13, 290.20, 290.21, 290.3, 290.40-290.43, 290.8, 290.9, 293.0, 293.1, 293.81-293.84, 293.89, 293.9, 294.0, 294.10, 294.11, 294.20, 294.21, 294.8, 294.9, 295.00, 295.01-295.05, 295.10-295.15, 295.20-295.25, 295.30-295.35, 295.40-295.45, 295.50-295.55, 295.60-295.65, 295.70-295.75, 295.80-295.85, 295.90-295.95, 296.00-296.06, 296.10-296.16, 296.20-296.26, 296.30-296.36, 296.40-296.46, 296.50-296.56, 296.60-296.66, 296.7, 296.80-296.82, 296.89, 296.90, 296.99, 297.0, 297.1, 297.2, 297.3, 297.8, 297.9, 298.0, 298.1, 298.2, 298.3, 298.4, 298.8, 298.9, 299.00, 299.01, 299.10, 299.11, 299.80, 299.81, 299.90, 299.91, 300.00-300.02, 300.09-300.16, 300.19-300.23, 300.29, 300.3, 300.4, 300.5, 300.6, 300.7, 300.81, 300.82, 300.89, 300.9, 301.0, 301.10-301.13, 301.20-301.22, 301.3, 301.4, 301.50, ICD-9-CM Diagnosis 301.51, 301.59, 301.6, 301.7, 301.81-301.84, 301.89, 301.9, 302.0, 302.1, 302.2, 302.3, 302.4, 302.50-302.53, 302.6, 302.70-302.76, 302.79, 302.81-302.85, 302.89, 302.9, 306.0, 306.1, 306.2, 306.3, 306.4, 306.4, 306.50-306.53, 306.59, 306.6, 306.7, 306.8, 306.9, 307.0, 307.1, 307.20-307.23, 307.3, 307.40-307.54, 307.59, 307.6, 307.7, 307.80, 307.81, 307.89, 307.9, 308.0, 308.1, 308.2, 308.3, 308.4, 308.9, 309.1, 309.21-309.24, 309.28, 309.29, 309.3, 309.4, 309.81-309.83, 309.89, 309.9, 310.0, 310.1, 310.2, 310.81, 310.89, 310.9, 311, 312.00-312.03, 312.10-312.13, 312.20-312.23, 312.30-312.35, 312.39, 312.4, 312.81, 312.82, 312.89, 312.9, 313.0, 313.1, 313.21-313.23, 313.3. 313.81-313.83, 313.89, 313.9, 314.00, 314.01, 314.1, 314.2, 314.8, 314.9, 315.00-315.02, 315.09, 315.1, 315.2, 315.31-315.35, 315.39, 315.4, 315.5, 315.8, 315.9, 316 ICD-10-CM Diagnosis Use the appropriate code family: F CPT HCPCS Follow-up visits identified by the following CPT or HCPCS codes with any practitioner within 7 and 30 days of ED Visit. Stand Alone Visits: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99495, 99496, 99510 Telehealth Modifier: 95, GT CPT Stand Alone Visits: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 POS Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876 WITH Follow-Up Group 2: 99221-99223, 99231-99233, 99238, 99239, 99251-99255 WITH 52, 53 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) dependence, and who had a follow-up visit for AOD. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. ICD-9-CM Diagnosis ICD-10-CM Diagnosis AOD: 291.0-291.5, 291.81, 291.82, 291.89, 291.9, 303.00-303.02, 303.90-303.92, 304.00-304.02, 304.10-304.12, 304.20-304.22, 304.30-304.32, 304.40-304.42, 304.50-304.52, 304.60-304.62, 304.70-304.72, 304.80-304.82, 304.90-304.92, 305.00-305.02, 305.20-305.22, 305.30-305.32, 305.40-305.42, 305.50-305.52, 305.60-305.62, 305.70-305.72, 305.80-305.82, 305.90-305.92, 535.30, 535.31, 571.1 Use the appropriate code family: F 2018 Behavioral Health Resource Guide 11

CPT HCPCS Follow-up visits identified by the following CPT or HCPCS codes with any practitioner within 7 and 30 days of ED Visit. Stand Alone Visits: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404,99408, 99409, 99411, 99412, 99510 Telephone Visits: 98966-98968, 99441-99443 Online Assessment: 98969, 99444 Telehealth Modifier: 95, GT CPT Stand Alone Visits: G0155, G0176, G0177, G0396, G0397, G0409- G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0022, H0031, H0034-H0037, H0039, H0040, H0047, H2000, H2001, H2010-H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015 POS Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, 90832-90834, 90836-90840, 90845, 90847, 90849, 90853, 90875, 90876 Follow-Up Group 2: 99221-99223, 99231-99233, 99238, 99239, 99251-99255 Use of Opioids at High Dosage (UOD): WITH WITH 03, 05, 07, 09, 11-20, 22, 33, 49, 50, 52, 53, 57, 71, 72 52, 53 First-Year Measure For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] >120 mg). The average MED for all opioids dispensed during the treatment period. Calculate the number of days covered for all dispensing events and determine who meets the threshold of 15 total days covered during the measurement year. NOTE: A lower rate indicates better performance Opioid Medications: The following list of medications is based upon the 2018 HEDIS Technical Specifications. Please reference the State Formulary for covered medications. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. For Medicare, please refer to the WellCare Formulary. Prescription Buprenorphine Hydromorphone Opium Butorphanol Levorphanol Oxycodone Codeine Meperidine Oxymorphone Use of Opioids From Multiple Providers (UOP): Dihydrocodeine Methadone Pentazocine Fentanyl Morphine Tapentadol Hydrocodone Tramadol First-Year Measure For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers. Three rates are reported. 1. Multiple Prescribers: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers during the measurement year. 2. Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year. 3. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 of member receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year. NOTE: A lower rate indicated better performance for all three rates. Opioid Medications: The following list of medications is based upon the 2018 HEDIS Technical Specifications. Please reference the State Formulary for covered medications. Please refer to the Preferred Drug List (PDL) on the state-specific WellCare website for Medicaid drug coverage. For Medicare, please refer to the WellCare Formulary. Prescription Buprenorphine Hydromorphone Opium Butorphanol Levorphanol Oxycodone Codeine Meperidine Oxymorphone Dihydrocodeine Methadone Pentazocine Fentanyl Morphine Tapentadol Hydrocodone Tramadol 2018 Behavioral Health Resource Guide 12

Depression Screening and Follow-Up for Adolescents and Adults (DSF) First-Year Measure The percentage of members 12 years of age and older who were screened for clinical depression using an age-appropriate standardized tool and, if screened positive, who received follow-up care. Depression Screening: The percentage of members who were screened for clinical depression using a standardized tool. Follow-Up on Positive Screen: The percentage of members who screened positive for depression and received follow-up care within 30 days. Mental Illness: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F21-F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10-F30.13, F30.2-F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.2, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78, F31.81, F31.89, F31.9, F32.0-F32.5, F32.8, F32.81, F32.89, F33.0-F33.3, F33.40-F33.42, F33.42, F33.8, F33.9, F34.0, F34.1, F34.8, F34.81, F34.89, F34.9, F39, F42, F42.2-F42.4, F42.8, F42.9, F43.0, F43.10- ICD-10-CM Diagnosis F43.12, F43.20-F43.25, F43.29, F43.8, F43.9, F44.80, F53, F60.0-F60.7, F60.81, F60.89, F60.9, F63.0-F63.3, F63.81, F63.89, F63.9-F63.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8, F84.9, F90.0-F90.2, F90.8, F90.0, F91.0-F91.3, F91.8, F91.9, F93.0, F93.8, F93.9, F94.0-94.2, F94.8, F94.9 Mental Illness SNOWED: 1453 Depression: F01.51, F32.0-F32.5, F32.81, F32.89, F32.9, F33.0-F33.3, F33.42, F33.9, F34.1, F43.21, F43.23 Behavioral Health Encounter: 90791, 90792, 90832-90834, 90836-90839, 90845-90847, 90849, 90853, 90865, 90867-90870, 90875, 90876, 90880, 90887 ECDS Follow-Up: 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341- CPT Codes 99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412 Telephone Visits: 98966-98968, 99441-99443 Telehealth Modifier: 95,GT Behavioral Health Encounter: G0155, G0176, G0177, G0409-G0411, G0502, G0503, G0507, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 HCPCS ECDS Follow-up: G0463, T1015 Positive Depression Screen: G8431 Depression Screen: G8431, G8510, G8511 Unhealthy Alcohol Use Screening and Follow Up (ASF) First-Year Measure The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, who received appropriate follow-up care. Unhealthy Alcohol Use Screening: The percentage of members who had a systematic screening for unhealthy alcohol use. Counseling or Other Follow-Up: The percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening. ICD-10-CM Diagnosis Z71.41, Z71.89 Alcohol Counseling and Treatment: 99408, 99409 CPT Codes Alcohol Screening: 99408, 99409 CPTII:3016F Alcohol Counseling and Treatment: G0396, G0397, G0443, H0005, H0007, H0015, H0016, H0022, H0050, H2035, H2036, T1006, T1012 HCPCS Alcohol Screening: G0396, G0397, G0442, H0001, H0049 Telehealth Modifier: 95, GT 2018 Behavioral Health Resource Guide 13

Behavioral Health HEDIS Measures Requirements needed to demonstrate compliance with Behavioral Health HEDIS measure. This information is from the 2018 HEDIS Technical Specifications for health plans Measure Description Required Documentation Key Notes First-Year Measure Transitions of Care (TRC): Percentage of discharges for members 18 years of age and older who had each of the following during the measurement year. Four rates are reported: Notification of Inpatient Admission. Documentation of receipt of notification of inpatient admission on the day of admission or the following day. Receipt of Discharge Information. Documentation of receipt of discharge information on the day of discharge or the following day. Patient Engagement After Inpatient Discharge. Documentation of patient engagement (e.g., office visits, visits to the home, telehealth) provided within 30 days after discharge. Medication Reconciliation Post- Discharge. Documentation of medication reconciliation on the date of discharge through 30 days after discharge (31 total days). Follow-up post discharge to complete coordination of care and complete medication reconciliation through 30 days (31 total days) after discharge. Follow-up care can include office, home, and telehealth visits. Antidepressant Medication Management (AMM) The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment. The percentage of members who remained on an antidepressant medication for at least 180 days (6 months). Educate your patients on how to take their antidepressant medications. Important messages include: How antidepressants work, their benefits and how long they should be used Length of time patient should expect to be on the antidepressant before they start to feel better Importance of continuing to take the medication even if they begin feeling better Common side effects, how long the side effects may last and how to manage them What to do if they have questions or concerns 2018 Behavioral Health Resource Guide 14

Measure Description Required Documentation Key Notes Follow-up After Hospitalization for Mental Illness (FUH) The percentage of discharged members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days and 7 days after discharge. Two rates are reported: The percentage of discharges for which the member received follow up within 30 days after discharge. The percentage of discharges for which the member received followup within 7 days after discharge. Schedule the 7-day follow-up visit within 5 days to allow flexibility in rescheduling, if necessary. Involve the patient s caregiver regarding the follow-up plan after IP discharge. If the member s appointment does not occur within the first 7 days post-discharge, please schedule the appointment to occur within 30 days post-discharge. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET) The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) abuse or dependence from Jan. 1 Nov. 14 of the measurement year. Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth, or medication assisted treatment (MAT) within 14 days of the diagnosis. Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services, or MAT, within 34 days of the initiation visit. Schedule a follow-up appointment for members diagnosed with a new episode of alcohol or other drug (AOD) within 14 days of the diagnosis. Schedule the initial 14-day follow-up visit within 10 days of discharge to allow flexibility in rescheduling. Involve the patient s caregiver regarding the follow-up plan, if possible. At the end of the initial follow-up appointment, schedule two more follow-up appointments to occur within 34 days of the initial follow-up appointment. When treating a patient for issues related to an alcohol or other drug dependence diagnosis, code for that diagnosis on every claim. Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) The percentage of members 19 64 years of age with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. The percentage of members 18 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening during the measurement year. The percentage of members refill and stay on their medication for at least 80% of the treatment period. Members have either a glucose test or HbA1c during the measurement year. Encourage schizophrenic patients to discuss any side effects, take their medication as prescribed, and refill their medication on time. Encourage members with schizophrenia or bipolar disorder who are also on Antipsychotic Medication to get a diabetic screening. To increase compliance, consider using standing orders to get labs done. Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD) The percentage of members 18 64 years of age with schizophrenia and diabetes who had both an LDL-C and HbA1c. Members have both and LDL-C and HbA1c Schedule diabetes screening for members with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication. To increase compliance, consider using standing orders to get labs done. 2018 Behavioral Health Resource Guide 15

Measure Description Required Documentation Key Notes Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) The percentage of members 18 64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test. Members have an LDL-C test Encourage members with schizophrenia and cardiovascular disease to schedule a LDL-C test. To increase compliance, consider using standing orders to get labs done. Follow-up Care for Children Prescribed ADHD Medication (ADD) The percentage of children who were newly prescribed ADHD medication who had a least three follow-up care visits within a 10-month period, one which was within 30 days of when the first ADHD drug was dispensed. Two rates are reported: Initiation Phase members 6 12 years of age that had a follow-up visit within 30 days of the prescription written Continuation and Maintenance Phase members 6 12 years of age with an ambulatory prescription for ADHD medication, who remained on the medication for 210 days and who in a ddition to the 30 day visit had a least 2 follow-up visits with 270 days (9 months) after the initiation phase Members must have the following: 30 day follow-up visit after the initial prescription 2 additional follow-up visits after the 30-day visits within 270 days (9 months) When prescribing a new medication to your patient, be sure to schedule a follow-up visit within 30 days to assess how the medication is working and to address side effect issues. Schedule this visit (allow for time to reschedule prior to 30 days, if necessary) while your patient is still in the office. Schedule two more visits in the 9 months after the 30-day Initiation Phase to continue to monitor your patient s progress. Only one of the two visits (during days 31-300) may be a telephone visit or a telehealth visit. Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) The percentage of children and adolescents 1 17 years of age who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year. A lower rate of concurrent antipsychotics indicates better performance Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) The percentage of children and adolescents 1 17 years of age who had two or more antipsychotic prescriptions and had metabolic testing, both of the following: At least one blood glucose test or HbA1c At least one LDL-C test Member must have the following: A glucose blood test or HbA1c At least one LDL-C test Please schedule or ask the member s PCP to schedule an LDL-C or HbA1C test. To increase compliance, consider using standing orders to get labs done. 2018 Behavioral Health Resource Guide 16

Measure Description Required Documentation Key Notes Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) The percentage of children and adolescents 1 17 years of age who had a new prescription for an antipsychotic and had documentation of psychosocial care as first-line treatment. Member must have documentation of psychosocial care as first-line treatment (a trial of outpatient behavioral health therapy prior to initiation of medication therapy). Follow-Up After Emergency Department (ED) Visit For Mental Illness (FUM) The percentage of members 6 years of age and older who had an ED visit with a principal diagnosis of mental illness and who had outpatient visit, an intensive outpatient encounter or partial hospitalization with any practitioner within 30 days and 7 days after the ED visit. Two rates are reported: 1. The percentage of ED visits for which the member received followup within 30 days of the ED visit (31 total days). 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days). Schedule the 7-day follow-up visit within 5 days to allow flexibility in rescheduling, if necessary. Involve the patient s caregiver regarding the follow-up plan after ED discharge. If the member s appointment does not occur within the first 7 days post-ed visit, please schedule the appointment to occur within 30 days post-ed visit. Follow-Up After Emergency Department Visit For Alcohol And Other Drug Abuse or Dependence (FUA) The percentage of members 13 years of age and older who had an ED visit with a principal diagnosis of alcohol or other drug (AOD) dependence and who outpatient visit, an intensive outpatient encounter or partial hospitalization with any practitioner within 30 days and 7 days after the ED visit. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days). 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days). Schedule the 7-day follow-up visit within 5 days to allow flexibility in rescheduling, if necessary. Involve the patient s caregiver regarding the follow-up plan after ED discharge. If the member s appointment does not occur within the first 7 days post-ed visit, please schedule the appointment to occur within 30 days post-ed visit. 2018 Behavioral Health Resource Guide 17

Measure Description Required Documentation Key Notes Utilization of the PHQ-9 to The percentage of members 12 years of Selection of the appropriate assessment Monitor Depression Symptoms for age and older with a diagnosis of major should be based on the age of the member. Adolescents and Adults (DMS) depression or dysthymia, who have a PHQ-9: For 13 years of age and above. PHQ-9 tool administered at least once PHQ-9 Modified for Teens: For ages during a four-month period Depression Remission or Response for Adolescents and Adults (DRR) The percentage of members 12 years and older with a diagnosis of depression and an elevated PHQ-9 score who had a response or remission within 4-8 months of the elevated score. Two rates are reported. 1. ECDS Coverage. For those members 12 and older with a diagnosis of major depression or dysthymia for whom a health plan can receive any electronic clinical quality data. 2. Utilization of PHQ-9. The percentage of PHQ-9 utilization. Members with a diagnosis of major depression or dysthymia whose measure data are reportable using ECDS and, had an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter. Four rates are reported: 1. ECDS Coverage. Members for whom a health plan can receive any electronic clinical quality data. 2. Follow-Up PHQ-9. The percentage of members who have a follow-up PHQ-9 score documented within the four to eight months after the initial elevated PHQ-9 score. 3. Depression Remission. The percentage of members who achieved remission within 4 to 8 months after the initial elevated PHQ-9 score. Members who achieve remission of depression symptoms as noted by a PHQ-9 depression response score of less than 5 recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded. 4. Depression Response. The percentage of members who showed response within 4 to 8 months after the initial elevated PHQ-9 score. Members who indicate a response to depression treatment as noted by a PHQ-9 depression response score at least 50% lower than the PHQ-9 score associated with the Index Episode Start Date (IESD), recorded in the ECDS during the depression follow-up period. Must be the most recent score recorded. 12 18. The PHQ-9 assessment does not need to occur during a face-to-face encounter. For example, it can be completed over the telephone or through a Web-based portal Selection of the appropriate assessment should be based on the age of the member. PHQ-9: For 13 years of age and above. PHQ-9 Modified for Teens: For ages 12 18. The PHQ-9 assessment does not need to occur during a face-to-face encounter. For example, it can be completed over the telephone or through a Web-based portal. 2018 Behavioral Health Resource Guide 18

Measure Description Required Documentation Key Notes First-Year Measure Use of Opioids at High Dosage (UOD): First-Year Measure USE of Opioids From Multiple Providers (UOP): First-Year Measure Depression Screening and Follow-Up for Adolescents and Adults (DSF): For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] more than 120 mg). For members 18 years and older, the rate per 1,000 receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers. The percentage of members 12 years of age and older who were screened for clinical depression using an age-appropriate standardized tool and, if screened positive, who received follow-up care. A lower rate indicates better performance Three rates are reported: Multiple Prescribers: The rate per 1,000 of members receiving prescriptions for opioids from four or more different prescribers during measurement year. Multiple Pharmacies: The rate per 1,000 of members receiving prescriptions for opioids from four or more different pharmacies during the measurement year. Multiple Prescribers and Multiple Pharmacies: The rate per 1,000 of member receiving prescriptions for opioids from four or more different prescribers and four or more different pharmacies during the measurement year. NOTE: A lower rate indicated better performance for all three rates. Depression Screening: The percentage of members who were screened for clinical depression using a standardized tool. Follow-Up on Positive Screen: The percentage of members who screened positive for depression and received follow-up care within 30 days. Guideline on opioid prescribing for chronic, non-malignant pain recommend the use of additional precautions when prescribing dosages 50 morphine equivalent dose (MED) and recommends avoiding increasing dosages 90mg MED or to carefully justify dosages 90mg MED (CDC, 2016). For members who are already taking doses 90mg MED, the CDC recommends that providers should explain in a nonjudgmental manner the risks and benefits of continuing high-dose opioids, and should offer these members the opportunity to taper to a safer, lower dose. Guideline on opioid prescribing for chronic, non-malignant pain recommend the use of additional precautions when prescribing dosages 50 morphine equivalent dose (MED) and recommends avoiding increasing dosages 90mg MED or to carefully justify dosages 90mg MED (CDC, 2016). For members who are already taking doses 90mg MED, the CDC recommends that provider should explain in a nonjudgmental manner the risks and benefits of continuing high-dose opioids, and should offer these members the opportunity to taper to a safer, lower dose. Selection of the appropriate assessment should be based on the age of the member. PHQ-9 For 13 years of age and above. PHQ-9 Modified for Teens ages 12-18. The PH-Q-9 assessment does not need to occur during a face-to-face encounter; for example, it can be completed over the telephone or through a web-based portal. Schedule follow-up appointment for members with positive screen to receive appropriate care. 2018 Behavioral Health Resource Guide 19

Measure Description Required Documentation Key Notes First-Year Measure Unhealthy Alcohol Use Screening and Follow Up (ASF): The percentage of members 18 years of age and older who were screened for unhealthy alcohol use using a standardized tool and, if screened positive, received appropriate follow-up care. Unhealthy Alcohol Use Screening: The percentage of members who had a systematic screening for unhealthy alcohol use. Counseling or Other Follow-Up: The percentage of members who screened positive for unhealthy alcohol use and received brief counseling or other follow-up care within 2 months of a positive screening. The assessment does not need to occur during a face-to-face encounter. For example, it can be completed over the telephone or through a web-based portal. Schedule follow-up appointment for members with positive screen to receive appropriate care. WellCare s Clinical Practice Guidelines for Behavioral Health can be found at www.wellcare.com. You can find some helpful information for your patient in regard to certain behavioral health issues in the link: wellnessproposals.com/wellness-library 2018 Behavioral Health Resource Guide 20

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Quality care is a team effort. Thank you for playing a starring role! PRO_04232E Internal Approved 11282017 WellCare 2017