Ala. Admin. Code r. 560-X-37-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-37-.09 - Attribution Under The Alabama Coordinated Health Network Program

(1) Under the Alabama Coordinated Health Network (ACHN) Program, Medicaid recipients will be attributed to Primary Care Physician (PCP) Groups based on the historical visitation practices of the Medicaid recipient. Attribution is the process that will be used to associate a Medicaid recipient to the PCP Group that provides primary care to that recipient. Under the ACHN Program, PCP Groups will be eligible to receive bonus payments based on having a completed ACHN PCP Group Agreement with the Medicaid Agency, a PCP Network Participation Agreement with an ACHN, and meeting participation requirements as identified in the Participation Agreement; in addition to meeting quality measures, cost effectiveness measures, and Patient Centered Medical Home Recognition. If a PCP Group is eligible to receive bonus payments, the amount of the bonus payments payable to a PCP Group will be determined by the number of recipients attributed to the PCP Group. On a quarterly basis, the Medicaid Agency will perform attribution for each Medicaid recipient under the ACHN Program in accordance to the following process:

(a) The Medicaid Agency will review the previous two (2) year history of doctor visit utilization for each Medicaid recipient. Utilization will consist of preventive visits and regular office visits. A PCP is defined, by specialty, as Family Practice, Pediatricians, Internists, General Practitioners, FQHCs, RHCs, and Nurse Practitioners /Physicians Assistants in a PCP Group. When in the best interest of a patient (e.g., children with special health care needs), a nontraditional PCP specialty may consider as a PCP. Physicians with other specialties may be considered for PCP participation if willing to meet active participation requirements. All other providers are deemed specialists.

(b) Points will only be awarded for claims that are in a paid status before the end of the attribution run period.

(c) The Medicaid Agency will review the previous twelve (12) month history of filled prescriptions for chronic care conditions for each Medicaid recipient.

(d) The point values described below associated with the visits and prescriptions will be assigned to the individual doctor that performed the service. The individual PCP scores will be combined to form the PCP Group's total point score.

(e) PCP Groups will receive points based on the number of preventive visits and regular office visits conducted by the PCP Group. Preventive visits will receive a higher point value. Visits that have occurred more recently will receive a higher point value. Visits with a PCP will receive a higher point value than visits with a specialist.

(f) PCP Groups will receive points based on the number of prescriptions filled for chronic care conditions. For the purposes of this rule, prescriptions for chronic care conditions shall mean more than one prescription filled for a chronic condition (e.g., asthma) and must correspond to an office visit from the prescribing provider within the previous two (2) years.

(g) The PCP Group with the highest number of points will have the Medicaid recipient attributed to that PCP Group. The Medicaid recipient must have been eligible for the ACHN program for three (3) out of the previous twenty-four (24) months to be attributed.

(h) If a specialist group has the highest number of points, then the specialist group will be attributed the Medicaid recipient; however, a specialist group shall not be eligible to receive the bonus payments described above.

(2) A PCP Group may request the attribution calculation for any Medicaid recipient the PCP Group has provided primary care services for in the preceding two-year period. If a PCP Group believes the Medicaid Agency has not properly attributed one or more Medicaid recipients to the PCP Group, it may request the Medicaid Agency reconsider its attribution calculation.

(a) A request for reconsideration must be submitted to the Medicaid Agency in writing and within seven (7) business days of the quarterly attribution notification. The written request for reconsideration must contain the period of attribution, the Medicaid recipient(s) the PCP Group believes was/were not properly attributed, and supporting information and/or documentation demonstrating that the Medicaid Agency either failed to or improperly considered information which had a material impact on the result of the attribution.

(b) The PCP Group that has been attributed the Medicaid recipient(s) subject to the request for reconsideration shall be notified by the Medicaid Agency of the request and be permitted to submit information for Medicaid Agency consideration within three (3) business days of the notice.

(c) The Medicaid Agency will review all relevant information and complete any adjustments to the PCP Group's Medicaid recipient attribution within seven (7) business days of receipt of the request for reconsideration.

Ala. Admin. Code r. 560-X-37-.09

Adopted by Alabama Administrative Monthly Volume XXXVII, Issue No. 12, September 30, 2019, eff. 10/12/2019.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 03, December 31, 2019, eff. 2/14/2020.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 07, April 30, 2020, eff. 6/14/2020.

Amended by Alabama Administrative Monthly Volume XLI, Issue No. 02, November 30, 2022, eff. 1/14/2023.

Author: Travis D. Houser, Director, Managed Care Operations Division

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. Part 438.