CurrentUnitedHealthcarePolicy N/A

Medical Condition Assessment Incentive Program (MCAIP) terms

Governance of UnitedHealthcare's MCAIP that defines eligibility, reporting, payment structure, audits, training, overpayment recovery, termination, and dispute resolution for participating Providers and Provider Physicians.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Condition Assessment Incentive Program (MCAIP) terms

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionAllow United employees access to electronic medical records or permit chart reviews and attest quarterly to demographic accuracy to remain eligible for MCAIP bonus payments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$20Payment per Suspect Medical Condition assessed

$10Fully Assessed MCAIP Customer bonus per condition

150dSuperior Bonus payment window

120dFinal report available

30dOverpayment repayment window

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MCAIP Payment and Compliance Criteria

MCAIP payment and compliance criteria

Conditions for receiving MCAIP Bonus payments and additional Fully Assessed and Superior bonuses:

ALL of the following

Provider must have access to Practice Assist or a comparable platform and must have received and returned any required amendment to participate in the MCAIP.
Provider must be assigned/attributed MCAIP Customers by United to be eligible for payments.

ALL of the following

When Suspect Medical Condition is assessed as present
- Provider Physician assesses the Suspect Medical Condition as present during a care visit and Provider timely submits a claim that includes complete and accurate ICD-10-CM code(s).
When Suspect Medical Condition cannot be diagnosed at visit
- Provider Physician documents in Practice Assist that the Suspect Medical Condition could not be diagnosed at the time of the care visit and reports the fact and date through Practice Assist in a timely manner.
Timeliness thresholds: claims are considered timely if processed and/or paid by United no later than March 31 following the end of the applicable MCAIP Term; Practice Assist submissions are timely if submitted no later than January 10 following the end of the applicable MCAIP Term (United may use supplemental CMS-compliant data submitted by that date).

ALL of the following

MCAIP Bonus calculation: $20.00 multiplied by the total number of Suspect Medical Conditions that Provider Physicians assessed for MCAIP Customers during the MCAIP Term.
Fully Assessed MCAIP Customer Bonus: an additional $10.00 multiplied by the total number of Suspect Medical Conditions fully assessed for that MCAIP Customer during the MCAIP Term; paid quarterly per the MCAIP payment schedule.
Payment schedule: quarterly submission windows and corresponding payment dates are specified (examples: Jan–Mar submissions processed through 5/31 with payment 7/31; Apr–Jun processed through 8/31 with payment 10/31; Jul–Sep processed through 11/30 with payment 1/31; Oct–Dec processed through 3/31 with payment 5/31). United will review prior quarters and make additional payments if applicable.

ALL of the following

Provider is eligible for the Medical Condition Assessment Superior Bonus if Provider achieves an Average Star Rating within MA-PCPi of at least 4.00 AND addresses at least 65% of the Suspect Medical Conditions for MCAIP Customers during the MCAIP Term.
United will calculate the Superior Bonus as the applicable PMPY payment amount (per the table) multiplied by the total number of MCAIP Customers identified on the final report and will pay the Superior Bonus no later than 150 days after the end of the MCAIP Term.

ALL of the following

United will provide monthly reporting and update Practice Assist monthly to reflect Provider activity and allow documentation of undiagnosed Suspect Medical Conditions.
United may conduct quality reviews, access electronic medical records or perform chart reviews for CMS-required submissions, and require Providers to attest quarterly to the accuracy of demographic data per the Administrative Guide.
If records are incomplete or not furnished within specified timeframes, if Provider fails to attest to demographic accuracy, fails to comply with coding/risk adjustment standards, or fails to use Practice Assist for undiagnosed conditions, United may reduce or withhold some or all MCAIP Bonus payments.
United will offer training at no cost; identified Provider employees must attend within the timeframe established by United or United may reduce or withhold payment.

ALL of the following

If Provider qualifies for bonuses, eligibility to receive any Bonus when an Agreement is not in effect at payment time is at United's discretion.
United will make a final report available to Provider no later than 120 days after the end of the MCAIP Term (monthly reporting provided during the Term).

Diagnosis Coding and Bonus Eligibility

Diagnosis coding requirementICD-10Covered

ICD-10-CM

Claims must include complete and accurate ICD-10-CM code(s) when a Suspect Medical Condition is diagnosed.

Superior Bonus eligibility thresholds

Eligibility thresholdProvider must achieve an Average Star Rating within MA‑PCPi of at least 4.00 and address at least 65% of Suspect Medical Conditions for MCAIP Customers during the MCAIP Term.

PMPY tier: 95%+$125.00 PMPY per MCAIP Customer as noted in final reporting.

PMPY tier: 85%–94%$100.00 PMPY per MCAIP Customer as noted in final reporting.

PMPY tier: 80%–84%$75.00 PMPY per MCAIP Customer as noted in final reporting.

PMPY tier: 75%–79%$50.00 PMPY per MCAIP Customer as noted in final reporting.

PMPY tier: 65%–74%$25.00 PMPY per MCAIP Customer as noted in final reporting.

Provider Responsibilities, Access, Quality Review, and Termination

Documentation Required

Provide EMR access/permit chart review and attest quarterly

Provider must allow identified United employees access to electronic medical records or, alternatively, permit United or its designee to conduct chart reviews of the Provider's records for CMS-required data submission for any or all MCAIP Customers. Provider must also attest quarterly to the accuracy of demographic data as described in the UnitedHealthcare Care Provider Administrative Guide; failure to furnish records within the specified timeframe, provide complete records, or to attest to demographic accuracy may result in reduction or withholding of MCAIP bonus payments.

Allow identified United employees EMR access or permit United/designee chart reviews for CMS-required submissions.
Quarterly attestations to the accuracy of demographic data are required.
Incomplete records, untimely responses, or failure to attest may lead to reduction or withholding of bonus payments.

Denial Risk

Expect United quality reviews; payments may be withheld for noncompliance

Key MCAIP Definitions

Suspect Medical Condition definition

DefinitionSuspect Medical Condition: A potential condition that United believes that a MCAIP Customer has but that has not been reported during the MCAIP Term on a claim or encounter.

IdentificationSuspect Medical Conditions are those identified by United for MCAIP Customers and included in Practice Assist and final reporting.

Reporting implicationProviders must assess and document Suspect Medical Conditions per MCAIP reporting requirements to receive MCAIP payments.

MCAIP Customer definition

DefinitionMCAIP Customer: Each Customer eligible for and enrolled in a Medicare Advantage Benefit Plan who is assigned and/or attributed, for a given MCAIP Term, by United to one of Provider Physicians and identified by United on the PCOR as eligible for the MCAIP.

Eligibility

Policy Summary

PayerUnitedHealthcare

PolicyMedical Condition Assessment Incentive Program (MCAIP) terms

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionAllow United employees access to electronic medical records or permit chart reviews and attest quarterly to demographic accuracy to remain eligible for MCAIP bonus payments.

SourceLink

On This Page

United will pay the Superior Bonus no later than 150 days after the end of the MCAIP Term.

United reserves the right to conduct quality reviews and to reduce or withhold payment for assessments if it determines the Provider Physician failed to conduct assessments, did not comply with relevant risk-adjustment or coding requirements, or did not use Practice Assist to report Suspect Medical Conditions that were assessed but not diagnosed at the visit. Failure to timely comply with these requirements allows United to reduce or withhold MCAIP payments.

United may perform quality reviews to validate assessments and reporting.
Withholding or reduction of payments may occur for failure to conduct assessments, noncompliance with coding/risk-adjustment standards, or failure to use Practice Assist for reporting.

Note

Termination rights and immediate termination for noncompliance

Either Provider or United may terminate the Provider's participation in MCAIP with the required advance notice for the next MCAIP Term; additionally, either party may terminate participation immediately on notice if the other fails to comply with any requirement of these Terms and Conditions. United may also immediately terminate participation if the Provider no longer meets United's participation requirements. If United terminates MCAIP during a Term, the Provider will not be entitled to payment under MCAIP for that Term; continuation in other United incentive programs is at United's discretion.

Provider may terminate participation effective for the next MCAIP Term by giving notice within 60 days after Terms for the next Term are communicated.
United may terminate participation effective for the next MCAIP Term by giving at least 30 days' notice prior to the start of the next Term.
Either party may terminate immediately upon notice for failure to comply with these Terms; United may immediately terminate if Provider no longer meets participation requirements.
Participation in MCAIP does not guarantee continuation in other United incentive programs; continuation is at United's sole discretion.

Customer must be enrolled in a Medicare Advantage Benefit Plan and assigned/attributed by United to a Provider Physician to be an MCAIP Customer.

Use in calculationsFinal reporting identifies MCAIP Customers used to calculate Fully Assessed and Superior Bonuses.

MCAIP Term definition

DefinitionMCAIP Term: A calendar year during which Provider is eligible to participate in MCAIP (for example, January 1, 2023 through December 31, 2023).

Reporting deadlinesPractice Assist submissions for October–December quarter are timely if submitted by January 10 following the MCAIP Term; final report available no later than 120 days after Term end.

Payment timing referenceSuperior Bonus paid no later than 150 days after the end of the MCAIP Term.

Provider Physician definition

DefinitionProvider Physician: A physician who is a doctor of medicine or osteopathy, duly licensed and qualified under the laws of the jurisdiction in which he/she provides health services, or a registered nurse practitioner or physician assistant as permitted by United’s credentialing plan and state law, who meets participation criteria.

AssociationEach Provider Physician is assigned to a specific Provider based on whether they are a party to an Agreement or participate under a United participation agreement/provider contract.

Role in MCAIPProvider Physicians perform assessments of Suspect Medical Conditions that drive MCAIP Bonuses and reporting obligations.