VBP TERMS
HIGH-UTILIZER
WHAT IS A MEMBER WHO FREQUENTS THE HOSPITAL/ER
HOW MANY PATIENT IDENTIFIERS DO YOU NEED TO VERIFY IDENTITY?
WHAT IS TWO
(NAME<DOB>MEMBER NUMBER>PHONE>ADDRESS)
GSD
WHAT IS Glycemic Status Assessment for Patients with Diabetes
(The GSD (Glycemic Status Assessment for Patients with Diabetes) measure is part of the HEDIS framework, focusing on the percentage of members aged 18–75 with diabetes whose most recent glycemic status (HbA1c or GMI) falls within specific levels. The goal is to have a glycemic status of less than 8.0% and to monitor those with levels greater than 9.0%. This measure is essential for assessing the effectiveness of care in managing diabetes and reducing complications. To identify eligible patients, both claims/encounter data and pharmacy data are utilized)
THE VISIT THAT IS COMPLETED ONCE A YEAR FOR EVERY MEDICARE MEMBER
WHAT IS AWV (ANNUAL WELLNESS VISIT)
MEASURE THAT ENCOURAGES PROVIDERS TO ASSESS A MEMBER'S 3-21 yo HEALTH AND WELLNESS YEARLY
MER or MLR
WHAT IS MEDICAL EXPENSE RATIO or
WHAT IS MEDICAL LOSS RATIO
(Medical loss ratio (MLR) is a measure of the percentage of premium dollars that a health plan spends on medical claims and quality improvements, versus administrative costs. The Affordable Care Act (ACA) set minimum MLR standards for health insurance in the US. )
DOCUMENT/GUIDE USED TO DECIDE WHAT CODES TO CLOSE A CARE GAP IN EQUIPO
WHAT IS CLOSING CARE GAPS WITH CLAIMS
EED
WHAT IS: Eye Exam for Patients With Diabetes. Patients with diabetes—eye exams
(Record your efforts: • A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year. • A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. • Bilateral eye enucleation any time during the member’s history through December 31 of the measurement year.)
FORM USED FOR MEMBERS OVER 66yo
WHAT IS: CARE OF OLDER ADULT FORM
(COA)
PAIN ASSESSMENT
FUNCTIONAL STATUS ASSESSMENT
MEDICATION REVIEW
MEASURE THAT ENCOURAGES PROVIDERS TO HAVE 6 VISITS WITH MEMBERS PRIOR TO 30 MONTHS OLD
WHAT IS WC30
Well child 30
SDoH
WHAT ARE SOCIAL DETERMINANTS OF HEALTH
(Non-medical factors that influence health outcomes)
CODES THAT CLOSE CARE GAPS ELECTRONICALLY/SOMETIMES REFERRED TO AS "F" CODES
WHAT IS CPT II CODES
SPD or SUPD
WHAT IS:
Statin Therapy for Patients With Diabetes—
Received Statin Therapy
WELLCARE FORM THAT OFFERS AN ADDITIONAL INCENTIVE TO PROVIDERS
WHAT IS APPOINTMENT AGENDA
COC
MEMBERS THAT DO NOT VISIT THE ASSIGNED PROVIDER
WHAT IS NON-USERS
IPA
WHAT IS INDEPENDENT PRACTICE ASSOCIATION
COMPLIANT BLOOD PRESSURE
WHAT IS <140/90
TRC
WHAT IS: Transitions of Care
—Notification of Inpatient Admission—65+ Transitions of Care
—Receipt of Discharge Information—65+ Transitions of Care—receipt of discharge information
—Patient Engagement After Inpatient Discharge—65+ Transitions of Care—patient engagement after inpatient discharge
—Medication Reconciliation Post-Discharge
30days
ALEDADE HOUSES WHAT MEMBERS
WHAT IS STRAIGHT MEDICARE
MEMBERS SHOULD BE SEEN 7-84 DAYS AFTER THIS EVENT
WAHT IS PPC
Postpartum care
PPE
WHAT IS POTENTIALLY PREVENTABLE EVENTS
(HOSPITAL ADMISSIONS<READMISSIONS<ER VISITS THAT COULD HAVE BEEN PREVENTED BY AN OFFICE VISIT OR REFERRAL)
MAY MONTHLY CONCENTRATION
WHAT IS MEDICAID WELL VISIT SCHEDULING
IMA
WHAT IS: Immunizations for Adolescents
One dose of the meningococcal vaccine.
One Tdap (tetanus, diphtheria, and pertussis) vaccine.
FORM THAT OFFERS HUMANA PROVIDERS AN ADDITIONAL $150 INCENTIVE
WHAT IS PAF
PROVIDER ASSESSMENT FORM
MEMBERS CAN DO WHAT TO CHANGE THE PCP
WHAT IS CALL FIDELIS
NUMBER ON THE BACK OF THE CARD OR ONLINE FIDELIS MEMBER PORTAL