The following guidelines apply to our Medicare Quality Incentive Program; participation in the program is voluntary.

To be eligible for an incentive payment, you must have an active Medicare Advantage provider agreement in good standing at the time of incentive payment. This includes participating in required compliance or Quality Program activities (e.g., timely submission of requested medical records for HEDIS risk adjustment reviews). If your agreement is terminated or we receive notice from you to terminate your agreement, you will not be eligible to receive any incentive payment.

Gaps can be closed via claim submission, the care gap management application (CGMA) or a supplemental electronic medical record (EMR) data extract, as specified below for each component. For measures that may be monitored more than once a year, such as HbA1c or blood pressure, we will use the final reading of the calendar year to determine compliance. Please be sure to report each reading or test result throughout the year.

Deadlines for gap closure (received by us):

• CGMA – February 28, 2022
• EMR data extract – February 28, 2022
• Medical claims – March 31, 2022
• Pharmacy claims – March 31, 2022

We strongly encourage use of the CGMA, monthly EMR supplemental files, and/or claims to submit Medicare Quality Incentive Program data. However, if fax is the only option, we require the use of our QIP fax coversheet. Submissions that do not include the QIP fax coversheet will be returned unprocessed. The QIP fax coversheet is available in the CGMA and in the Printed material section under Medicare.

Medicare Star Rating gap compliance will be determined using HEDIS 2020 criteria for the 2020 program and HEDIS MY2020 criteria for the 2021 program. If HEDIS guidelines change mid-year, the most recent version of HEDIS criterial will be used. Performance will be determined using the Asuris-generated 1- to 5- Star Rating threshold based on publicly available CMS data.

Our threshold targets are set at or above the current CMS published thresholds to ensure continued quality of care.

For more information, please refer to the CMS contract performance threshold methodology and historical cut points.

We reserve the right to determine final eligibility for payment of incentive at our discretion.

Your provider agreement with us must be in good standing at the time of the incentive payment distribution to receive any earned incentive payment, including participation in required compliance of quality program activities (e.g., timely submission of requested medical records for HEDIS or risk adjustment reviews). If your agreement is terminated or we receive notice from you to terminate your agreement, you will not be eligible to receive any incentive payment.

We may review data submitted to validate documentation. If the results of a review indicate that coding does not meet support completeness, gaps will be reopened.

Incentive payments amounts will be calculated based on attribution as indicated in your patient roster effective December 31 of the program year.

Incentive payment will be made by June 30, of the year following the program year. Any disputes of the payment amount or incentive qualification must be submitted in writing to us within 30 days of the date on the check.

If you have questions about the incentive program, measure criteria, gap data submission requirements or EMR data extract specifications, please email us.

All attribution changes must be submitted via the CGMA on or before September 30 of the program year. From October 1 to December 31, you will be able to submit changes for newly attributed members only.

Total cost of care (TCC) and HMO members are contractually assigned and/or attributed and cannot be removed through the CGMA. Contact your provider experience manager if you have questions about the locked membership tied to one of these contract arrangements.

We may review data submitted for completeness. If the results indicate that coding does not support completeness, the gaps will be reopened so the provider can address them at subsequent visits.

We may review provider-initiated attribution changes that appear to be excessive in relation to the network-wide averages.