query-orchestration/assets/sampleOne/tx_74-28.txt

Document Index
COLLABORATIVE CLINICAL ENGAGEMENT   1INCENTIVE PROGRAM EXHIBIT   1
4. Collaborative Clinical Engagement Bonus.   2
PROVIDER: DUMMY PHYSICIANS ALLIANCE   3
COLLABORATIVE CLINICAL ENGAGEMENT   4INCENTIVE PROGRAM EXHIBIT   4
SCHEDULE A   4



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COLLABORATIVE CLINICAL ENGAGEMENT
INCENTIVE PROGRAM EXHIBIT
This Collaborative Clinical Engagement Incentive Program Exhibit (this "Exhibit") to the Value Based Program
Addendum is effective as of
9/1/2020
("Exhibit Effective Date").
Provider shall be eligible for a population health management stipend ("Collaborative Clinical Engagement Bonus")
under the Collaborative Clinical Engagement Incentive Program ("CCE") and under the terms and conditions as set
forth herein for actively engaging with Health Plan and achieving performance improvements for a selected quality
based measure as set forth below in Table 1. The parties to this Exhibit agree and acknowledge that compensation
paid to Provider under this Program is not intended to and does not provide incentives to Provider or the Practitioners
(as defined herein) to deny, limit, reduce or discontinue medically appropriate Covered Services to any Covered
Person.
1. Definitions. The following definitions shall apply for the purposes of this Exhibit. Capitalized terms not defined
in this Exhibit shall have the meanings ascribed to them in the Agreement.
a. "Assigned Covered Person" means a Covered Person who is assigned on an exclusive basis to a Practitioner
by Health Plan, who is not excluded from the CCE by Plan and is eligible to receive Covered Services through
MCO in the following MCO Products: STAR, CHIP, STAR+PLUS (non-duals), STAR+PLUS MMP, STAR
Health, STAR Kids and Medicare Advantage (D-SNP and MA-PD).
b. "Contract Year" means each twelve (12) month period during the term of this Exhibit beginning as of the
CCE Effective Date.
C.
"Incentive Payment" means any payment by Plan to Provider that does not constitute a payment of claims
for Covered Services provided to Covered Persons.
d.
"Practitioner" means a licensed health care professional who is an employee or contractor of Provider and
who is a Participating Provider under the Agreement.
2.
Collaborative Clinical Engagement Services. Provider or Practitioner, as applicable, shall perform the selected
services defined in Schedule A ("Engagement Activity") of this Exhibit for Assigned Covered Persons
("Collaborative Clinical Engagement Services").
3. Eligibility for Collaborative Clinical Engagement Bonus.
a. Eligibility Criteria for Collaborative Clinical Engagement Bonus. Provider shall be eligible for a
Collaborative Clinical Engagement Bonus if: (1) at least ninety percent (90%) of the Practitioners' panels are
open for Covered Persons at all times during the then-current Contract Year; (2) Provider is participating in
the Plan's value based shared savings program during the then-current Contract Year; (3) Provider provides
population health management services to Covered Persons; (4) Provider select a quality measure and
engagement frequency goal (e.g. 80% of 26 meetings per 12 month period - Provider schedules/participates
in bi-weekly meetings with Plan's engagement teams to address collaboration goals, care coordination and
outcome measures); and (5) meets all other thresholds and requirements set forth in this Exhibit and the
Agreement.
b. Disciplinary Action. If any Practitioner has been identified for quality-related remediation or disciplinary
action, Plan reserves the right in its sole discretion to withhold, and to cause Provider to forfeit, any amount
that would otherwise have been payable as a Collaborative Clinical Engagement Bonus hereunder
attributable to that Practitioner.
PPA_TX_Jan2018
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4. Collaborative Clinical Engagement Bonus.
PMPM. As compensation for Collaborative Clinical Engagement Services furnished by Provider hereunder, Plan
shall pay Provider a Collaborative Clinical Engagement Bonus in the total amount of:
$2.00 per Assigned Covered Person per month (itemized below)
a. Engagement Activity. One dollar ($1.00) per Assigned Covered Person per month
a. Provider must meet with Plan engagement staff the agreed upon engagement frequency Provider
selects in Schedule A.
b. PMPM paid to Provider by the 15th of each month during each Contract Year
b. Quality Measure Outcomes. One dollar ($1.00) per Assigned Covered Person per month
a. Provider must meet the quality measure goal for the agreed upon quality measure Provider selects
in Schedule A.
b. PMPM paid to Provider at the end of the Contract Year
c. Bonus Offset. CCE Bonus paid under this Exhibit will be deducted from incentives paid under the
Provider's Value Based Program Addendum for the Contract Year in which the Exhibit terms, if
applicable.
d. Repayment. No later than 120 days after the end of each Contract Year, Plan shall calculate the
compliance rate for the provider selected Engagement Activity and Quality Measure. Please see
additional calculation information in Schedule A. attached hereto and incorporated herein. If the
provider selected target compliance percentage for Engagement Activity is less than or equal to 75% of
the required goal for the Contract Year, Provider shall repay Plan fifty percent (50%) of the Collaborative
Clinical Engagement Bonus paid for the applicable Contract Year. Such repayment shall be in the form
of, at Plan's option, a recoupment from any incentive payment or combination thereof, or an offset of
future bonus payments payable in connection with any subsequent Contract Year. Plan shall be solely
responsible for the methodology used, and the final calculation indicated above.
5. Term and Termination. The term of this Exhibit is 12 months beginning the first day of the month after the
Provider agrees through the execution of this exhibit to participate in the Collaborative Clinical Engagement
Program. Either party may terminate participation of Provider and the Practitioners in the Collaborative Clinical
Engagement Program for any reason prior to the expiration or termination of the Agreement upon ninety (90)
days prior written notice to the other party. In the event of such termination, or any termination of the Agreement,
Provider shall not be eligible for payment of any unpaid Collaborative Clinical Engagement Bonus corresponding
to the Contract Year in which such termination is effective, and this Exhibit and the Collaborative Clinical
Engagement Program will be of no further force and effect.
6. Modifications. Plan reserves the right to amend the terms and conditions of this Exhibit, unilaterally upon thirty
(30) days prior notice to Provider. If changing only Schedule A, Health Plan agrees to provide the revised
Schedule A to Provider no less than thirty (30) days prior to the start of the Contract Year.
7. Regulatory Requirements. Provider agrees that, in connection with any Medicare and Medicaid products,
Provider shall and shall prohibit the Practitioners and other persons under contract with Provider from claiming
payment in any form directly or indirectly from a federal health care program (as that term is defined in Section
1128B(f) of the Social Security Act, 42 U.S.C. 1320a-7b(f)) for items or services covered under this Agreement.
Provider and each Practitioner acknowledge and agree (i) that it, he or she has not given or received remuneration
in return for or to induce the provision or acceptance of business (other than business covered by this Agreement)
for which payment may be made in whole or in part by a federal health care program on a fee-for-service or cost
basis; and (ii) that it, he or she will not shift the financial burden of this Agreement to the extent that increased
payments are claimed from a federal health care program.
PPA_TX_Jan2018
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Funds distributed by Plan to Provider under this Exhibit during each Contract Year, combined with all other
Incentive Payments made to Provider by Plan during such Contract Year, may not exceed thirty-three percent
(33%) of total claims payments made by Plan to Provider during such Contract Year. Limitations to Incentive
Payments for provider to remain under the 33% threshold shall be made in the sole discretion of Plan.
IN WITNESS WHEREOF, the parties hereto have executed this Addendum including Schedule A, effective as of the
date first above written.
SHP: XYZ HEALTH PLAN Inc.
PROVIDER: DUMMY PHYSICIANS ALLIANCE
Authorized Signature
Authorized Signature
Paunth
Smith
-
Printed Name: Harvey Specter
Printed Name: Luis Litt
Title: President & CEO
Title:
President
Signature Date: 09/16/2020
Signature Date:
8/26/2020
TIN: 12-3456789
PPA_TX_Jan2018
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COLLABORATIVE CLINICAL ENGAGEMENT
INCENTIVE PROGRAM EXHIBIT
SCHEDULE A
A.
Collaborative Clinical Engagement Services may include, but are not limited to:
Collaborate with Plan to assess current population health practices.
Provide care coordination services to Covered Persons.
Agree to meet with Plan engagement team on a regularly scheduled basis to evaluate Quality Measure
performance, collaboration opportunities and population health best practices.
Assist Health Plan with the collection of HEDIS data via medical record information.
Provide regular reports regarding activities and outreach to Covered Persons.
Choose one Quality Measure set forth below in Table 1, to be evaluated for the quality bonus.
Table 1.
B.
Due to the constraints of COVID-19, virtual visits using a technology platform will substitute for in-person
visits through December 31st, 2020, The necessity for virtual visits will be monitored on a monthly basis
through the term of this agreement and conclude when deemed safe by the Centers of Disease Control, HHSC
or Plan.
Choose one engagement goal set forth below in Table 2, to be evaluated for the Engagement Activity bonus.
PPA TX Jan2018
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-------Table Start--------
d9a31643-2162-4bfc-8825-3bb1735b1814
[['Quality Measure', 'Goal (Completion Rate = Network Average)', 'Requirement', 'Measurement', 'Provider Selection (Initial 1 Box)'], ['Chronic Care Visits', '89.35% (Completion Rate)', 'Coordinate care for this patient population by ensuring 3 or more visits are completed with a qualified physician', "Percent of the provider's panel with one or more dominant chronic conditions that have three or more qualified physician visits", None], ['Well Visit for Infant', '67.46% (Completion Rate)', 'Schedule the patient with this care gap for a visit with their PCP and complete the wellness visit', "Percent of provider's eligible panel that received 6 or more pediatric well- visits for infants from birth to 15 months", None], ['Well Visit for Child 3 to 6 Years of Age', '71.08% (Completion Rate)', 'Schedule the patient with this care gap for a visit with their PCP and complete the wellness visit', "Percent of provider's eligible panel (children aged 3 to 6 years) that received at least 1 pediatric well-visit within the 12 rolling month period", None], ['Post-Discharge Follow-Up', '76.07% (Completion Rate)', 'Schedule the patient a follow up visit with their PCP within 30 days (preferably within 7 days) after discharge from an inpatient stay', "Percent of the provider's panel that visited a physician office within 30 days post-discharge", None], ['PCP Visit', '82.05% (Completion Rate)', 'Ensure patients have at least 1 visit to their assigned PCP annually', "Percent of the provider's panel visiting a Primary Care Provider", None], ['Generic Rx', '80.86% (Completion Rate)', 'When appropriate and available, prescribe a generic drug', "Percent difference between a physician's expected generic prescription rate and current actual rate of generic drug prescriptions (from all physicians seen by the members)", None], ['Manage PHN and EHN Member Lists', '90.00% (Outreach Success Rate for Compliant Members - Minimum 2 Outreach calls per attempt)', 'Review a list of EHN an PHN members; outreach to these members once a month', "Percent of provider's eligible panel placed on a care management plan with a successful outreach (if outreach was not successful, 2 attempts must be made per call as determined by care management plan (if 0 successful outreaches are made in a quarter, then member will be deemed ineligible for the measure)", None], ['Colorectal Cancer Screening', '10,73% (Completion Rate)', 'Review the care gap with your patient and assist in coordinating care; ensure completion of screening', "Percent of provider's eligible panel that received colorectal cancer screening (colonoscopy-centric) within the 12 rolling month period", None], ['Breast Cancer Screening', '51.39% (Completion Rate)', 'Review the care gap with your patient and assist in coordinating care; ensure completion of screening', "Percent of provider's eligible panel that received a mammogram within the 12 rolling month period", None]]
 Table 1. B. Due to the constraints of COVID-19, virtual visits using a technology platform will substitute for in-person visits through December 31st, 2020, The necessity for virtual visits will be monitored on a monthly basis through the term of this agreement and conclude when deemed safe by the Centers of Disease Control, HHSC or Plan.
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Table 2.
PPA_TX_Jan2018
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-------Table Start--------
23bbd93b-ece1-4dff-8f19-53b739cd168e
[['Required Engagement Frequency', 'Engagement Percentage Goal', 'Time Requirement', 'Provider Selection (Initial 1 Box)'], ['Virtual visits once a month with weekly calls', '90% Visit Compliance 80% Call Compliance', 'Quarter day (2 hours) observation and half day (4 hours) strategic planning', '8th'], ['Virtual visits twice a month with weekly calls', '80% Visit Compliance 80% Call Compliance', 'Quarter day (2 hours) observation and half day (4 hours) strategic planning', None], ['Bi-monthly virtual visits with 2 calls a week (weekly planning and status)', '100% Visit Compliance 85% Call Compliance', 'Half day (4 hours) observation and half day (4 hours) strategic planning', None]]
 Table 2.
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Signature:
That
Signature:
Email: dummy.email@company.com
Email: replacement.email@company.com