Updated quality performance requirements
This provider bulletin is an update about information in the Medicaid Business Provider Operations Manual (POM) for Anthem Blue Cross (Anthem). For access to the latest manual, go online to https://providers.anthem.com/ca. Please note that the manual is considered part of your provider agreement, and its provisions are contractual requirements.
The California Department of Health Care Services (DHCS) requires managed care plans (MCPs) to meet the 50th percentile or minimum performance level (MPL) for a select set of quality measures also known as the Managed Care Accountability Set (MCAS). When the MPL is not met on any measure within MCAS, DHCS may impose the following actions on the MCP:
- Corrective Action Plan (CAP)
- Plan Do Study Act cycle (PDSA)/Performance Improvement Plan (PIP)
As a result, Anthem has implemented quality performance requirements that require all applicable network providers, including safety net clinics, independent practitioners, primary medical groups/individual practice associations, public hospitals, and other health systems to meet the MPL for all measures with the DHCS selected MCAS measures. Anthem will closely monitor performance and hold providers accountable for meeting the MPL. Low performing providers will be subject to the following process:
- Anthem will send provider Notice of Noncompliance or Corrective Action Plan (CAP)
- Provider will have 30 days from CAP issuance to respond with a data driven improvement action plan.
- Anthem will continuously monitor provider’s performance throughout the
- Provider will have through the end of the current measurement year in which the CAP is issued to improve HEDIS®
- The CAP will remain in place until final HEDIS rates are available in the following year and can be ongoing based on HEDIS performance.
- Failure to improve rates will result in formal contractual
Anthem will be monitoring and strictly enforcing this process effective immediately. If you have any questions, please contact your local quality associate contact.
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August 2022 Anthem Blue Cross Provider News - California