Updated quality performance requirements

This provider bulletin is an update about information in the Anthem Blue Cross (Anthem) Medicaid Business Provider Operations Manual (POM). 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)
• Sanctions
• 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 for non-compliance or CAP.
• Provider will have 10 days to respond with an improvement action plan.
• Anthem will continuously monitor provider’s performance throughout the year.
• Provider will have four months to improve rates.
• Failure to improve rates will result in formal contractual actions.

 

Anthem will be monitoring and strictly enforcing this process effective immediately.

 

If you have any questions, please contact your local Quality associate contact.