Product Lines:
Priority Partners.

Eligible Population:
Adults enrolled in a disabled coverage group (SSI) aged 21-64 years old as of December 31 of the measurement. This includes Population Health Incentive Program (PHIP) and HealthChoice Performance Measure reporting for Priority Partners.

Definition:
Adults enrolled in a disabled coverage group (SSI) aged 21-64 years as of December 31 of the measurement year who meet all of the following criteria during the calendar year:

• Enrolled in a disabled coverage group for 320 or more days.
• Enrolled in a single HealthChoice MCO for 320 or more days.
• Enrolled in the HealthChoice MCO as of December 31 of the measurement year.
• Had no more than one gap in enrollment of up to 45 days during the measurement year.
• Enrolled in a disabled coverage group on December 31 of the measurement year. 

The disabled coverage groups include the following eligibility categories:

• S01: Public Assistance to Adults
• S02: SSI Recipients
• S98: ABD – Medically Needy
• H01: HCBS Waiver and PACE participants
• A04: Disabled adults, no Medicare, up to 77% FPL

Best Practice and Measure Tips

This measure excludes

• Inpatient admissions and emergency department services.
• Members in hospice or using hospice services any time during the measurement year.

This measure includes

• Ambulatory care visits with a behavioral health diagnosis code (mental or chemical dependency), if those visits were covered by the MCO.
• At least one ambulatory care visit in an office, or a virtual visit, or any PCP outpatient visit. Preventative well visits preferred.

Documentation via claims

• This is a Maryland Department of Health (MDH) custom measure and reporting is captured by billing encounter codes only.

Measure Codes

• Urgent care center visit 
  • HCPCS: S9083, S9088
• Telephone/Telehealth Visits:
  • Telephone Visits CPT: 98966, 98967, 98968, 99441, 99442, 99443
  • Telehealth (E-visit or virtual check-in):
    
    • CPT: 98970, 98971, 98972, 98980, 98981, 99421, 99422, 99423, 99457, 99458
    • HCPCS: G0071, G2010, G2012, G2250, G2251, G2252
  • Telehealth Place of Service (POS) (Telehealth POS Value Set): 02, 10: 
    
    • 02: Telehealth Provided Other than in Patient’s Home
    • 10: Telehealth Provided in Patient’s Home
• Ambulatory Outpatient Visit:
  • CPT: 92002, 92004, 92012, 92014,99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99483
  • HCPCS: G0463, G0402, G0438, G0439, G0463, S0620, S0621, T1015**
    
    • NOTE: **T1015 HCPCS code which identifies an all-inclusive clinic visit for services rendered at a Federally Qualified Health Center (FQHC)
  • UBREV: 0510, 0511, 0513, 0514, 0515, 0516, 0517, 0519, 0520, 0521, 0522, 0523, 0524, 0525, 0526, 0527, 0528, 0529, 0982, 0983