2022-21: PMPM Quality Incentive Program Changes Coming January 1, 2023
Date: 10/27/22
Beginning January 1, 2023, our Per Member Per Month (PMPM) quality incentive program for our in-network primary care providers will change to a per code incentive program.
This new approach of moving to a service level per code incentive will provide less administrative burden, increase cash flow for closing care gaps, and remove thresholds for payouts. The per code measurement will be based on a calendar year reporting period.
2023 Incentive Measures | Procedure Code |
| Breast Cancer Screening (BCS) | 77061, 77062, 77063, 77065, 77066, 77067 |
| Cervical Cancer Screening (CCS) | 87620, 87621, 87622, 87624, 87625, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175 |
| Child and Adolescent Well-Care Visits (WCV) | 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461, G0438, G0439, S0302, S0610, S0612, S0613 |
| Colorectal Cancer Screening (COL) | 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345, 45346, 45347, 45349, 45350, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45388, 45389, 45390, 45391, 45392, 45393, 45398, 74261, 74262, 74263, 81528, 82270, 82274 |
| Controlling High Blood Pressure (CBP) | 3074F, 3075F, 3079F |
| Developmental Behavioral Screening | 96110 |
| Follow-up After Emergency Department Visit for Mental Illness (FUM) | 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 98960, 98961, 98962, 98966, 98967, 98968, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99441, 99442, 99443, 99483, 99495, 99496, 99510 |
| Follow-up After Emergency Department Visit for Substance Abuse (FUA) | 98960, 98961, 98962, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99408, 99409, 99411, 99412, 99483, 99510 |
| Follow-up After Hospitalization for Mental Illness (FUH) | 90791, 90792, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 98960, 98961, 98962, 99078, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99233, 99234, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99510 |
| Hemoglobin A1c Control for Patients with Diabetes (HBD) | 3044F, 3051F |
| Hepatitis C Virus (HCV) Screening | 86803, 86804, 87520, 87521, 87522 |
| Human Papillomavirus (HPV) Vaccine | 90649, 90650, 90651 |
| Influenza Vaccine (FLU) | 90655, 90657, 90660, 90661, 90662, 90672, 90673, 90685, 90686, 90687, 90688, 90689, G0008 |
| Post Partum Care (PPC) | 0503F, 59430 |
| Progesterone Treatment (17P) | 96372, J3490 |
| Sexually Transmitted Infection (STI) Screening | 86592, 86695, 86696, 86703, 87340, 87491, 87591 |
| Alcohol and/or Drug Screening
| H0049 |
Alcohol and/or Drug SRVC BRF per 15 Min | H0050 |
Alcohol and/or Substance Abuse | 99408 |
As a valued provider in our network, you do not need to do anything to participate in this incentive program.
For questions or additional support, please contact your dedicated Provider Network Specialist or call Provider Services at 1-866-595-8133.