Provider Alert! Provider Incentive Program Updates

Attention: All PCP Providers
Effective Date: May 7, 2020

Call to action: Texas Children’s Health Plan (TCHP) would like to inform you of changes to our Provider Incentive Program (PIP) Upper Respiratory Infection measure to align with the changes consistent with National Committee for Quality Assurance (NCQA) HEDIS technical specifications. The Health and Human Services Commission (HHSC) follows this guidance as well in their oversight of Managed Care Organizations.

How this impacts providers: Updates include the following for measure, Appropriate Treatment for Upper Respiratory Infection (URI).

• Expanded age range to members 3 months of age and older.
  • Changed from 3 months -18 years to 3 months and above.
• Changed the measure from a member-based denominator to an episode-based denominator. This could increase the denominator.
  • Continuous enrollment is only 34 days long (no gaps allowed)
    • 30 days prior to event, event day plus three days after (34 days)
  • Removed the requirement to exclude episode dates where there was any diagnosis other than upper respiratory infection on the same date. This could increase the denominator.
  • Revised the Episode Date (ED) definition, removed the Index Episode Start Date (IESD) definition and added the Negative Comorbid Condition History definition.
  • Outpatient visits that result in an inpatient stay are excluded as an eligible event.
  • Duplicate eligible events are removed from the event/diagnosis criteria for more accurate results.
  • Added telehealth visits to the event/diagnosis criteria.
  • Penicillin G Benzathine is included to the “Natural penicillin” description

Please note that historical data from Immtrac and Texas Medicaid Healthcare Partnership (TMHP) claims data are included to calculate the HEDIS scores for the performance period.

Next steps for providers: Providers should become familiar with the changes to the Provider Incentive Program and implement protocols to improve the compliance rate if needed.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers