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Date: January 31, 2020
To: Health Plan of San Joaquin (HPSJ) Contracted Physicians
From: Health Plan of San Joaquin
Subject: Provider Alert – Value Based Payment (VBP) program – Coming Soon
Business: Medi-Cal

Dear Health Plan of San Joaquin Contracted Provider,
Health Plan of San Joaquin (HPSJ) is pleased to announce that it is preparing to implement the Department of Health Care Services (DHCS) Value Based Payment (VBP) program, funded by Proposition 56. The funding allocation for the VBP program is contingent upon DHCS VBP program approval, which is currently in a draft state. HPSJ is unable to execute the VBP program payments until the State finalizes this approval but can prepare our provider network in anticipation of this approval.

WHAT’S THE VBP PROGRAM?
VBP program will provide incentive payments to providers for meeting specific measures aimed at improving care for certain high-cost or high-need populations. Incentive payments are for VBP measures in the following areas:

  • Behavioral Health Integration
  • Chronic Disease Management
  • Prenatal/Post-Partum Care
  • Early Childhood Prevention

THE VBP PROGRAM 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.

CRITICAL INFORMATION ABOUT THE VBP PROGRAM SUPPLEMENTAL PAYMENTS

  • Use of the HPSJ VBP Coding Specifications Guide is required to obtain supplemental payment(s)
  • HPSJ Coding Specifications Guide is subject to change without notice and the most updated version will be published at HPSJ.com once finalized
  • Claim resubmission procedures will be addressed in HPSJ VBP trainings and HPSJ VBP program materials

KEY DATES FOR THE VBP PROGRAM

Date Description

July 1, 2019 VBP codes retro-effective date
February/March 2020 HPSJ Custom VBP Provider Services Training (in provider office)
March/April 2020 HPSJ Provider Network “Dinner and Learn” Program (on HPSJ campus)

WHAT CAN I DO NOW TO PREPARE FOR THE VBP PROGRAM?
Become familiar with ICD-10 codes for “Substance Use Disorder”, “Serious Mental Illness”, “Homelessness”, and “Inadequate Housing” as these codes will be used for “At-Risk Add-On” determination justification.

WHAT’S NEXT?
Schedule a VBP in office training by contacting your HPSJ Provider Services Representative or by emailing  HPSJ Provider Services at: ProviderServices@HPSJ.com  We encourage your key team members that assist in billing and coding to attend the training.

PROVIDER DISPUTE RESOLUTION PROCESS
HPSJ providers should refer to the HPSJ Provider Manual for full details on our Dispute Resolution procedure available at: https://www.hpsj.com/providermanual/

For your convenience attached is a summary of VBP measures that will be discussed during your training.  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 being one of our valued partners and your continued support of Health Plan of San Joaquin.

PROPOSED VALUE BASED PAYMENTS PROGRAM MEASURES & REIMBSUREMENTS

Domain

Measure

Add-On Amount

At-Risk Add-On Amount

Prenatal/Postpartum Care Bundle Prenatal Pertussis (‘Whooping Cough’) Vaccine $25.00 $ 37.50
Prenatal/Postpartum Care Bundle Prenatal Care Visit $70.00 $105.00
Prenatal/Postpartum Care Bundle Postpartum Care (Early or Late) Visits $70.00 $ 105.00
Prenatal/Postpartum Care Bundle Postpartum Birth Control $25.00 $ 37.50
Early Childhood Bundle Well Child Visits in First 15 Months of Life $70.00 $105.00
Early Childhood Bundle Well Child Visits in 3rd – 6th Years of Life $70.00 $105.00
Early Childhood Bundle All Childhood Vaccines for Two Year Olds $ 25.00 $37.50
Early Childhood Bundle Blood Lead Screening $25.00 $37.50
Early Childhood Bundle Dental Fluoride Varnish $25.00 $37.50
Chronic Disease Management Bundle Controlling High Blood Pressure $40.00 $60.00
Chronic Disease Management Bundle Diabetes Care $80.00 $120.00
Chronic Disease Management Bundle Control of Persistent Asthma $40.00 $60.00
Chronic Disease Management Bundle Tobacco Use Screening $25.00 $37.50
Chronic Disease Management Bundle Adult Influenza (‘Flu’) Vaccine $25.00 $37.50
Behavioral Health Integration Bundle Screening for Clinical Depression $50.00 $75.00
Behavioral Health Integration Bundle Management of Depression Medication $40.00 $60.00
Behavioral Health Integration Bundle Screening for Unhealthy Alcohol Use $50.00 $75.00
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