Issue link: https://www.e-digitaleditions.com/i/55648
This data is collected and used to rate the quality of MCE's. NCQA promotes quality through the ac- creditation process and publishes HEDIS data for public view. There are over 70 HEDIS measures related to children and adults getting well- ness care. These quality measures include data about the rates of well child care, timeliness of prenatal and postpartum care, and indicators for comprehensive diabetes care such as an annual LDL-C test. MCE's are required to incentivize providers to meet certain quality of care goals in accordance with Federal and State Pay for Performance Pro- grams (P4P). The quality goals that MCE's must meet are often HEDIS goals established by NCQA. Both commercial and government health plans use HEDIS quality goals to mea- sure and incentivize quality of care for their enrolled members. The P4P programs are meant to encourage im- provement and reward the healthcare providers for certain performance measures for quality and efficiency. Cooperative Managed Care Services (CMCS) assists providers in meeting quality of care goals in several ways. Our RN care managers provide tel- ephonic care management to chroni- cally ill members, such as persons with diabetes, and help engage them in their care. If gaps in care are discov- ered, the nurse care manager will reach out to members to provide education about the importance of comprehen- sive care for persons with diabetes. Our healthcare coordinators can also call the members to remind them to see their Primary Medical Provider for diabetes care to get LDL-C testing and to have an annual dilated retinal exam. CMCS provides data about members who are in need of services to pro- vider offices, so that gaps in care can be closed. For additional information about these services, please contact Linda Grosser in Quality Manage- ment at 317-575-7553. * For more information about NCQA and HEDIS: http://ncqa.org/tabid/59/ Default.aspx CMCS Implements NCCI Edits with Claim- C Check® By Cheryl Hobbs-Ferguson ooperative Managed Care Services (CMCS) has recently implemented a comprehensive code auditing solution called ClaimCheck® that includes the required National Correct Coding Initiatives (NCCI) edits. The Centers for Medicare and Medicaid Services (CMS) developed the NCCI to promote standardized correct coding methodologies and to reduce inappropriate payment due to improper coding. NCCI-specific files and the NCCI Policy Manual, as well as other publications related to NCCI claim editing, are located on the CMS Web site at http://www.cms.gov/Nation- alCorrectCodInitEd/. Providers not Line Number 01 02 Line Number 01 02 Date of Service 11/15/2011 11/15/2011 Date of Service 11/15/2011 11/15/2011 Procedure Code 99213 96150 Procedure Code 80061 80069 familiar with NCCI claim editing are encouraged to access this site for educational materials and to down- load NCCI Column I/II, Mutually Exclusive (ME), and Medically Un- likely Edit (MUE) files. ClaimCheck® increases the claims processing flexibility at CMCS NCCI Mutually Exclusive Edits identify code pairs that clinically would not be performed at the same anatomic site or during the same patient encounter or would produce the same results. ClaimCheck® increases the claims processing flexibility at CMCS, which allows us to meet the unique needs of each of our networks and providers. An example of bundled services is provided below. Any questions can be directed to the appropriate customer service representative listed on page 8. Description Office/Out- patient visit established Assess health behavior, initial Description Lipid panel Renal function panel NCCI Editing Detail is allowed Detail is denied NCCI Editing Detail is allowed Detail is denied NCCI Column I/Column II Edits identify pairs of Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be billed together because the component (Column II) code is bundled in the composite ( Column I) code or the two procedures can be represented by a more appropriate single code. CMCS connections 5 first qu arter 2012