Measures – Non-FQHC and Non-Clinic providers. Effective July 1, 2019

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Date: October 2, 2019
To: All Health Plan of San Joaquin (HPSJ) Contracted Practitioners
From: HPSJ Quality Management Department
Subject: DHCS Value Based Payment (VBP) Performance Measures – Non-FQHC and Non-Clinic providers. Effective July 1, 2019
Business: Medi-Cal

DHCS Value Based Payment (VBP) Performance Measures – Non-FQHC and Non-Clinic providers. Effective July 1, 2019  

California Governor Gavin Newsom and the Department of Health Care Services are invested in ensuring improvements in the quality of care provided to underserved CA residents, especially children. In response, the state has launched a Value Based Program wherein for select services the state pays an additional incentive amount for select services when complete and accurate data are provided. 

The state pays for these services based on the encounters that is received by DHCS. To receive the additional payment, you need to submit claims/encounters as the case maybe to the health plan and HPSJ sends it to the state. For members with a diagnosis of serious mental illness, substance use disorder diagnosis or if they are homeless there is an additional payment for the same select services. Per the state you will receive the payments retrospectively beginning July 1, 2019. 

A reference guide for selected services and the code and the additional payment for the services   is attached. 

Overarching Payment Conditions – Encounter data provided to Medi-Cal only! 

No chart review and no unmentioned supplemental data source is considered for reimbursement.

  • Medi-Cal administrative data reported through Managed Care Plans encounter data
  • Medi-Cal administrative data reported in the Medi-Cal Eligibility Data System
  • For immunization measures, the expectation is that immunizations reported through the CDPH California Immunization Registry (CAIR) 2.0 will be used as a supplemental data source.
  • For the Blood Lead Screening measure, the expectation is that the blood test results reported through the CDPH Blood Lead Registry may be used a supplemental data source.

Providers are identified based on:

  • National Provider Identifier (NPI) in the rendering, ordering, prescribing and/or billing field that is an NPI for an individual (Type 1).
  • To qualify for payment, providers must be practicing within their practice scope and must have an individual (Type 1) NPI. For example, if a pharmacist (not the pharmacy) provides an immunization, then that pharmacist could receive payment.

DHCS will be distributing the VBP incentive program funds through HPSJ based on the encounter data received by DHCS.

 EXCLUSIONS: Beneficiaries with Medicare Part B, and encounters occurring at Federally Qualified health Centers (FQHCs), Rural Health Clinics, American Indian Health Clinics, and Cost Based Reimbursement Clinics will be excluded from payment. If you have any questions, please contact our Provider Relations Department at: 209.942.6340; Monday – Friday, 8:00AM to 5:00PM


Posted on October 7th, 2019 and last modified on October 7th, 2019.