CurrentArizona Health Care Cost Containment SystemPolicy N/A

AHCCCS Differential Adjusted Payment (DAP) Activity

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This document governs CYE 2019 Differential Adjusted Payment increases for eligible Arizona AHCCCS providers and establishes performance, health information exchange, quality, prescribing, and participation criteria for enhanced reimbursement.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Differential Adjusted Payment (DAP) Activity

Policy CodePolicy N/A

Change TypePayment policy update

Effective DateOctober 1, 2018

Next Review DateN/A

Key ActionHospitals must submit a Letter of Intent to AHCCCS and the qualifying HIE and complete or maintain the required HIE milestones to receive the 3.0% DAP increase.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CYE 2019DAP payment period

3.0%-3.5%

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CurrentArizona Health Care Cost Containment SystemPolicy N/A

AHCCCS Differential Adjusted Payment (DAP) Activity

Customize your policy alerts

Sign up for all Arizona Health Care Cost Containment System policy alerts

Know when Arizona Health Care Cost Containment System releases new policies or updates existing guidance.

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Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Differential Adjusted Payment (DAP) Activity

Policy CodePolicy N/A

Change TypePayment policy update

Effective DateOctober 1, 2018

Next Review DateN/A

Key ActionHospitals must submit a Letter of Intent to AHCCCS and the qualifying HIE and complete or maintain the required HIE milestones to receive the 3.0% DAP increase.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CYE 2019DAP payment period

3.0%-3.5%

Potential hospital DAP increase

2%Nursing facility DAP increase

10%Integrated Clinic DAP increase

1%Practitioner DAP increase

40% / 60%Claims / e-prescription thresholds

Eligibility and Performance Criteria

Hospital HIE and certification criteria

Hospital DAP increases are available when the applicable criteria below are met.

Base HIE participation criteria

Hospital is an eligible APR-DRG hospital, psychiatric hospital, subacute facility (116 beds), rehabilitation hospital, or long-term acute care hospital.
Hospital submitted a Letter of Intent to AHCCCS and the qualifying HIE by June 15, 2018.
Hospital completed or maintained the required HIE milestones by the specified deadlines: executed an HIE agreement by July 31, 2018; approved a formal scope of work by October 31, 2018; submitted admission, discharge, and transfer information by March 31, 2019; and submitted the specified clinical and discharge information by June 30, 2019.

Additional pediatric emergency certification criterion

Hospital is an APR-DRG hospital.
Hospital obtained Pediatric-Prepared Emergency Care certification from the Arizona Chapter of the American Academy of Pediatrics by May 1, 2018.

Nursing facility quality criterion

Covered when all of the following are met:

ALL of the following

Facility is AHCCCS Provider Type 22 (Nursing Facility).
The facility's MDS 3.0 percentage of high-risk, long-stay residents with Stage II-IV pressure ulcers meets or falls below the applicable Arizona average, using the most recently published rate as of April 30, 2018.

Integrated Clinic eligibility and service criteria

Covered when all of the following are met:

ALL of the following

Provider is an AHCCCS-registered Integrated Clinic licensed by the Arizona Department of Health Services as an Outpatient Treatment Center and provides both behavioral health and physical health services.
Behavioral-health claims and encounters represent at least 40% of total AHCCCS claims and encounters, based on approved and adjudicated data for the applicable measurement period.
Clinic executed an agreement with a qualifying health information exchange organization by May 1, 2018 and electronically transfers both a registration event and an encounter summary to the HIE.

Electronic-prescribing performance criterion

Covered when all of the following are met:

ALL of the following

Practitioner is a physician, physician assistant, or registered nurse practitioner in the applicable AHCCCS provider types.
Practitioner has written at least 80 prescriptions for AHCCCS members.
At least 60% of the practitioner's total AHCCCS prescriptions are qualifying electronic prescriptions generated through a computer-to-computer electronic data interchange protocol, following a national industry standard, and identified by Origin Code 3.
Rendering provider ID on the claim matches the prescribing provider ID identified by AHCCCS as meeting the electronic-prescribing criteria.

Provider Types, Eligible Services, and Payment Parameters

AHCCCS provider typesmixed

02	Hospitals subject to APR-DRG reimbursement
71	Psychiatric hospitals
B5	Subacute facilities, 116 beds
C4	Rehabilitation hospitals and long-term acute care hospitals
22	Nursing facilities
IC	Integrated Clinics
08	Physicians
31	Physician assistants
18	Registered nurse practitioners
19	Registered nurse practitioners or other practitioner provider type as identified by AHCCCS

1–10 of 11

1/2

Integrated Clinic physical health services eligible for enhanced ratesCPTCovered

59400	Routine obstetric care including antepartum care and vaginal delivery
90471	Immunization administration
90472	Additional immunization administration
90473	Intranasal or oral vaccine administration
90474	Additional intranasal or oral vaccine administration
99201	New patient office or outpatient visit, typically 10 minutes
99202	New patient office or outpatient visit, typically 20 minutes
99203	New patient office or outpatient visit, typically 30 minutes
99204	New patient office or outpatient visit, typically 45 minutes
99205	New patient office or outpatient visit, typically 60 minutes

1–10 of 29

1/3

Qualifying electronic prescriptionsNDCCovered

Origin Code 3

Electronic prescription generated through computer-to-computer electronic data interchange using a national industry standard

Hospital HIE DAP increase

DAP increase3.0%

Applicable servicesInpatient and outpatient services

Payment periodCYE 2019 dates of service

Hospital HIE Letter of Intent deadline

Submission deadlineJune 15, 2018

Required submissionLetter of Intent (LOI)

Recipients

Participation, Payment, and Compliance Requirements

Note

Eligible Provider Categories

For CYE 2019, AHCCCS-registered Arizona providers in the designated categories may receive Differential Adjusted Payments when they meet the applicable performance criteria. Eligible categories are APR-DRG hospitals, other hospitals and inpatient facilities, nursing facilities, integrated clinics, and physicians, physician assistants, and registered nurse practitioners.

Documentation Required

Hospital HIE Participation Required

Hospitals seeking the 3.0% DAP increase for HIE participation must submit a Letter of Intent (LOI) to AHCCCS and the HIE by June 15, 2018. The LOI must commit the hospital to complete or maintain the required milestones through September 30, 2019.

Execute an agreement with a qualifying HIE by July 31, 2018.
Approve and authorize a formal scope of work by October 31, 2018.
Electronically submit admission, discharge, and transfer information, including emergency-department data when applicable, by March 31, 2019.

Key Policy Terms

Participation in the Network

LOI requirementSubmit a Letter of Intent to AHCCCS and the HIE

Participation requirementComplete or maintain the specified HIE milestone activities

Milestone activitiesHIE agreement, approved scope of work, ADT exchange, and exchange of clinical and discharge information

Care Coordination Agreement

Agreement typeWritten agreement

PartiesHospital and an IHS or Tribal 638 facility

Required provisions

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyAHCCCS Differential Adjusted Payment (DAP) Activity

Policy CodePolicy N/A

Change TypePayment policy update

Effective DateOctober 1, 2018

Next Review DateN/A

Key ActionHospitals must submit a Letter of Intent to AHCCCS and the qualifying HIE and complete or maintain the required HIE milestones to receive the 3.0% DAP increase.

SourceLink

On This Page

AHCCCS and the qualifying HIE

HIE milestone deadlines

Milestone 1July 31, 2018 — execute an agreement with a qualifying HIE organization

Milestone 2October 31, 2018 — approve and authorize a formal scope of work

Milestone 3March 31, 2019 — electronically submit ADT information

Milestone 4June 30, 2019 — electronically submit specified clinical and discharge information

Pediatric emergency certification increase

Additional DAP increase0.5%

CertificationPediatric-Prepared Emergency Care certification

Certification deadlineMay 1, 2018

Nursing facility pressure-ulcer benchmark

Performance measurePercentage of high-risk long-stay residents with Stage II-IV pressure ulcers

BenchmarkFacility percentage must meet or fall below the Arizona average

Data sourceMDS 3.0 results

Nursing facility DAP increase

DAP increase2%

Eligible providerNursing Facility, Provider Type 22

Qualifying conditionMDS 3.0 pressure-ulcer percentage meets or falls below the applicable Arizona average

Integrated Clinic behavioral-health claims threshold

Minimum thresholdAt least 40%

Calculation baseTotal AHCCCS claims and encounters

Data usedApproved and adjudicated AHCCCS claims and encounters

Integrated Clinic DAP increase

DAP increase10% over AHCCCS FFS rates

ServicesSelect physical health services

Payment periodCYE 2019 dates of service coinciding with the provider’s Integrated Clinic registration

Practitioner prescription volume threshold

Minimum prescription volumeAt least 80 AHCCCS prescriptions

Prescriber typesPhysicians, physician assistants, and registered nurse practitioners

Member populationAHCCCS members

Practitioner electronic prescription threshold

Minimum electronic-prescription rateAt least 60%

Calculation baseThe practitioner’s total AHCCCS prescriptions

Qualifying prescriptionsE-Prescriptions identified by Origin Code 3

Practitioner DAP increase

DAP increase1%

Applicable servicesCovered AHCCCS services billed on CMS Form 1500

Claim matching requirementRendering provider ID must match the qualifying prescribing provider ID

Minimum MCO entity payment threshold

Minimum payment threshold$25

Payment recipientEntity receiving an MCO payment

Payment timingAn amount below $25 may be delayed until payments reach at least $25 or the final CYE 2019 quarterly payment

By June 30, 2019, electronically submit applicable laboratory and radiology information, transcription, medication information, and discharge summaries containing the required clinical and transition-of-care elements.

Denial Risk

Missed HIE Milestones Risk Future DAP

A hospital that receives the CYE 2019 3.0% HIE-participation DAP but misses a milestone by its deadline or stops maintaining an achieved milestone becomes ineligible for any DAP for applicable CYE 2020 dates of service, if a DAP is available.

For milestones already achieved by June 15, 2018, the LOI must commit the hospital to maintain participation from June 1, 2018 through September 30, 2019.

Note

Pediatric Emergency Certification

An APR-DRG hospital may qualify for an additional 0.5% DAP increase by obtaining Pediatric-Prepared Emergency Care certification from the Arizona Chapter of the American Academy of Pediatrics (AzAAP) by May 1, 2018. Meeting both HIE participation and pediatric emergency certification criteria creates a potential 3.5% increase.

Documentation Required

Deferred Hospital Care Coordination DAP

AHCCCS may consider a CYE 2020 DAP increase for an APR-DRG hospital that collaborates to improve care for American Indian/Alaska Native members through a written care coordination agreement with an IHS or Tribal 638 facility.

By May 1, 2019, execute a written agreement providing for receipt of clinical-service referrals and a member-records and release-of-information protocol that returns clinical documentation to the IHS or Tribal 638 facility.
AHCCCS will monitor hospital activity under the agreement for compliance.

Note

Nursing Facility Pressure-Ulcer Performance

A Nursing Facility (Provider Type 22) qualifies for a 2% DAP increase when its performance for the MDS 3.0 high-risk, long-stay pressure-ulcer measure meets or falls below the applicable Arizona average.

AHCCCS uses approved and reported MDS 3.0 results for high-risk long-stay residents with Stage II-IV pressure ulcers.
The comparison uses the most recently published rate available as of April 30, 2018.

Documentation Required

Integrated Clinic Eligibility

An Integrated Clinic (Provider Type IC) must be registered as an AHCCCS Integrated Clinic, licensed by the Arizona Department of Health Services as an Outpatient Treatment Center, and provide both behavioral and physical health services. Behavioral health claims and encounters must represent at least 40% of total AHCCCS claims and encounters, and the clinic must participate in the HIE.

The 40% calculation uses approved and adjudicated AHCCCS claims and encounters for October 1, 2016 through September 30, 2017, computed as of May 1, 2018.
By May 1, 2018, execute an agreement with a qualifying HIE and electronically transfer a registration event and an encounter summary.
The resulting 10% increase applies to select physical-health services during CYE 2019 that coincide with the provider's registration as an Integrated Clinic.

Billing Rule

Practitioner E-Prescription Eligibility

Physicians, physician assistants, and registered nurse practitioners qualify for a 1% DAP increase on services billed on the CMS-1500 when they meet both the prescription-volume and electronic-prescribing thresholds.

Write at least 80 prescriptions for AHCCCS members.
Write at least 60% of total AHCCCS prescriptions as qualifying electronic prescriptions.
AHCCCS uses approved and adjudicated claims and encounters with July 1, 2017 through December 31, 2017 dispense dates, calculated as of May 1, 2018.
Qualifying electronic prescriptions are computer-to-computer transactions using a national industry standard and Origin Code 3; refills of qualifying original prescriptions are excluded.

Denial Risk

Match Rendering and Prescribing Provider IDs

The practitioner DAP applies only to covered AHCCCS claims when the rendering provider ID on the claim matches the prescribing provider ID that AHCCCS identified as meeting the e-prescription criteria.

Because of entity-based contracting operations, an MCO may pay the DAP other than on an individual-claim basis, at least quarterly.
If an expected quarterly payment to an entity is less than $25, payment may be delayed until payments reach $25 or the final CYE 2019 quarterly payment, whichever occurs first.

Billing Rule

MCO DAP Pass-Through

AHCCCS managed care organizations, including Regional Behavioral Health Authorities, must pass DAP increases through to their contracted providers while maintaining rates that match the corresponding AHCCCS Fee-for-Service rate-increase percentages.

Note

IHS and Tribal 638 Exemption

IHS and tribally owned or operated 638 facilities that qualify under the notice are exempt from the DAP initiative because their payments are primarily made at the federally mandated all-inclusive rate.

Note

Deferred Behavioral Health DAP

AHCCCS will consider a CYE 2020 DAP, effective for dates of service on and after October 1, 2019, for behavioral health providers serving Fee-for-Service AIHP members when the provider maintains the required access and participation conditions. The increase would apply to FFS rates for AIHP-enrolled members only after that effective date.

Effective October 1, 2018, accept and provide behavioral health services to FFS American Indian Health Program (AIHP) enrolled members; AHCCCS will monitor AIHP utilization for compliance.
Because AIHP establishes the provider relationship through the AHCCCS Provider Participation Agreement rather than individual MCO contracts, the provider must maintain that participation arrangement.
By May 1, 2019, maintain ACC Contractor contracts in the applicable geographic service area: 100% in the North GSA; 100% in the South GSA excluding Pima County; at least 2 of 3 contractors in Pima County; and at least 5 of 7 contractors in the Central GSA.
For DAP purposes, geographic service areas are the ACC GSAs, not the RBHA GSAs.

Referrals for clinical services, member records, and release-of-information protocols returning clinical documentation to the referring facility

Pediatric-Prepared Emergency Care certification

CertificationPediatric-Prepared Emergency Care certification

Issuing organizationArizona Chapter of the American Academy of Pediatrics (AzAAP)

Hospital deadlineCertification must be obtained by May 1, 2018

Integrated Clinic

LicensureLicensed by the Arizona Department of Health Services as an Outpatient Treatment Center

Services providedBehavioral health services and physical health services

AHCCCS designationIntegrated Clinic, Provider Type IC

E-Prescription

DefinitionA prescription generated through a computer-to-computer electronic data interchange protocol

StandardUses a national industry standard

IdentificationIdentified by Origin Code 3; refills of qualifying original prescriptions are excluded