Proposition 56 Funded ‐ Value Based Payment (VBP) program
| Date: | August 19, 2020 |
| To: | Health Plan of San Joaquin (HPSJ) Contracted Physicians |
| From: | HPSJ Claims Department |
| Subject: | Proposition 56 Funded ‐ Value Based Payment (VBP) program – Updates for 8/2020 |
| Business: | Medi-Cal |
Health Plan of San Joaquin (HPSJ) is working diligently to implement the supplemental payments for the Department of Health Care Services (DHCS) Value Based Payment (VBP) program. The following are update highlights.
MEASURE UPDATES
A). MEASURE #2 (PRENATAL CARE VISIT)
HPSJ will utilize the LMP date on the claim to assist in identifying the initial pregnancy visit. If you are not currently billing with the LMP in Box 14 of the CMS-1500 form, please ensure you are indicating this information moving forward. The absence of the LMP may delay your VBP payments.
Sample:
B). MEASURE #3 (POSTPARTUM VISIT) AND MEASURE #4 (POSTPARTUM BIRTH CONTROL)
DHCS requires the delivery date for Measures 3 & 4. While HPSJ will make every effort to validate the delivery date from the delivery claim, providers should start indicating the delivery date in box 15 of the CMS-1500 form, in an effort to expedite the validation process and subsequent supplemental payment.
Sample:
C). MEASURE #10 (CONTROLLING BLOOD PRESSURE) – CPT CODE VALIDATION
CPT codes 3074F, 3075F, 3078F, and 3079F are currently not Medi-Cal covered codes. For the purposes of the VBP supplemental payments, applicable claims include: (a) any claim with a date of service on or after 07/01/2019, as well as (b) any claim where one of the VBP qualifying codes for this measure was billed and denied. For non-VBP claims, this has no financial implications. To correct this issue HPSJ will:
- Internally (no provider claims re-submissions required at this time) reprocess all claims, retrospective to 7/1/19, with the CPT codes 3074F, 3075F, 3078F, and 3079F to pay $0.00
- And, all applicable claims with these codes will result in updated “remittance advice” notices for claims with above CPT codes
The above noted solution will translate into HPSJ more accurately identifying relevant DHCS VBP encounters for VBP Measure #10, without requiring a claim re-submission. We apologize for any inconvenience this may cause your office.
D). DISPUTING “NON‐PAYMENT” OF VBP SUPPLEMENTAL PAYMENT
In the event you feel a claim qualified but did not receive a supplemental payment, please file a dispute through the normal dispute process. Please ensure the dispute indicates it is a VBP dispute and advise which measure you feel the claim should have qualified for (example: VBP – Measure 2). Remember, for a claim to qualify for the VBP supplemental payment, the claim must:
- Meet all qualifying identifiers of the measure
- Be in a PAID
E). PDR VERSUS CORRECTED CLAIM
If you identify a qualified service was provided, but not billed:
- Submit a corrected claim
- DO NOT submit a dispute
If you received a VBP supplemental payment, that you believe qualified for the “at-risk” supplemental amount, please:
- Submit a dispute with supporting documentation
- DO NOT submit a corrected claim for at-risk only
DHCS VBP PROGRAM TRAINING
Earlier this year, HPSJ performed DHCS VBP provider trainings on May 28, 2020, 3:00 PM-4:30 PM and June 25, 2020, 7:30 AM-8:30 AM.
If you would like a DHCS VBP webinar training for your office, please set up a training with an HPSJ Provider Services Representative. You can do this by calling HPSJ Customer Service at 209.942.6320 (Monday – Friday, 8:00AM to 5:00PM).
For additional DHCS VBP information, please visit https://www.hpsj.com/value-based-payments/
PROGRAM UPDATES
- The VBP program is anticipated to continue at least through 6/30/21, at the sole discretion of the California Budget approval process.
- HPSJ anticipates monthly DHCS VBP supplemental payments, with the initial payment (for measures 1, 2, 3, 4, 5, 6, 8, 9, 11, 13, 14, 15, and 17 of the 17 VBP measures) in August 2020— retrospective to 7/1/19.
- DHCS VBP payments will be reflected in a separate “remittance advice” notice for VBP supplemental payments only
VBP PROGRAM EXCLUSIONS
- HPSJ will not be responsible for processing payment to providers NOT contracted with HPSJ.
- Others not included in the program are 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.
THANK YOU
We value you as a provider and look forward to ensuring your successful program participation. Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner. Thank you for your continued support and for being one of HPSJ’s valued partners.
PROPOSED DHCS VALUE BASED PAYMENTS PROGRAM MEASURES & REIMBURSEMENTS