Initial Health Appointment Tip Sheet

Incentives will be paid on an annual basis, following the end of Quarter 4. For additional information, refer to the CBI Technical Specifications.

All IHA visits require a:

• Comprehensive health history.
• Member Risk Assessment - These should include at least one of the following risk assessment domains:
  • Health Risk Assessment.
  • Social Determinants of Health (SDOH) screening tool to assess housing instability, functioning, quality of life outcomes and risk, utility needs, interpersonal safety, etc.
  • Cognitive Health Assessment
  • Adverse Childhood Experiences Screening.
• Physical exam.
• Mental status exam.
• Dental assessment. A review of the organ systems that include documentation of “inspection of the mouth” or “seeing dentist” meets the criteria.
• Health education/anticipatory guidance.
• Behavioral assessment.
• Diagnoses and a plan of care.

Note: For children and youth (i.e., individuals under age 21), Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screenings is covered in accordance with the American Academy of Pediatrics (AAP) /Bright Futures periodicity schedule.

1. Contacting newly linked members

• • Pull the list of newly linked Alliance members on a monthly basis. Your 120-day linkage list can be found on the Provider Portal:

1. 1. 1. Go to “Linked Member List” and click on the “New Members/120 Day IHA” tab.
      2. Review the list and remove patients who have already completed their IHA visit.

• • Assign a person (e.g., office manager or call center manager) to ensure new members are contacted.
  • Attempt to contact members at least three times. Document that you have made at least 3 unsuccessful attempts (2 phone calls and 1 mailing or vice versa).
  • Explain to your patients why this visit is important and reassure them that the cost of the visit is covered by the Alliance.

2. Preparing for IHA visits

• If using an EHR system:
  • Create a template for IHAs. Required elements include:
    • Comprehensive history.
    • Physical and mental status exam.
    • Individual health education.
    • Behavioral assessment.
    • Diagnoses.
    • Plan of care.
  • If using paper charts, create new patient paperwork packets specifically for IHAs.
  • IHAs require an extended visit. Establish a routine for scheduling IHAs when the most support staff is available or limit the number of IHAs scheduled per hour.
  • Suggestions for helping IHA visits go smoothly:
    • Call patients in advance and fill out their initial health history and SHA form over the phone or via your patient portal.
    • Assign two medical assistants per provider for IHA visits.
    • Brainstorm with your teams to come up with ideas on how they can assist with IHAs.

3. Ensuring accurate billing
   • Have a billing team member review your IHA billing practices.
   • Ensure that you are using the correct CPT and ICD 10 codes to reflect the components of the visit. (See full IHA code list)

When billing for IHAs, PCPs should use the appropriate CPT codes:

Note: Use of Z00.8 for inter-periodic health assessments will not count toward preventive exam frequency when billed with preventative CPT codes.

The Alliance has also implemented the IHA dummy code combination to allow providers to report certain exemptions to performing the IHA.   These exemptions include IHA completed 12 months prior to enrollment, members refusing an IHA, missed appointment or when they’ve attempted to schedule a member at least three times for their IHA appointment.

IHA 12 months prior to Medi-Cal enrollment
All elements of the IHA must be completed (including SHA) and if the members plan PCP did not perform the IHA within the last 12 months the PCP must record that the findings have been reviewed and updated in the members medical record.  For members who have become newly eligible or had a commercial insurance prior but remain at an established PCP office an IHA is needed if a SHA was not completed in the visit 12 months prior.

Refusal
A member or members parent(s) may refuse the IHA appointment, in this case documentation of refusal should be in members medical record along with any attempts to schedule the IHA.

Missed Appointment
Should a member miss a scheduled appointment, two additional attempts must be made to reschedule the appointment and documentation must live in members medical record.

3 Attempts to Schedule
Providers can make three documented unsuccessful scheduling attempts (2 telephone attempts and 1 written attempt) to qualify for the measure.

The following coding combination is required for all above listed examples:

Procedure code: 99499
Modifier: KX
ICD-10 Code: Z00.00

Members will be compliant for an IHA if the provider has submitted a claim or uploaded to the Data Submission Tool on the Alliance Provider Portal:

Note: The Alliance performs random audits to ensure that IHA dummy codes were submitted appropriately.

Data for this measure will be collected using claims and provider data submissions via the Data Submission Tool (DST) on the Provider Portal. To find gaps in data:

• Run a report from your electronic health record (EHR) system; or.
• Manually compile patient data. (Example: Download monthly Newly Linked Members and 120-Day Initial Health Assessment report on the Provider Portal and compare to EHR).

This measure allows providers to submit IHA dummy code combinations from the clinic EHR system or paper records to the Alliance by the DST contractual deadline. To submit, you may upload data files to the DST on the Provider Portal. To be accepted, data must be submitted as a CSV file. Step-by-step instructions are available in the Data Submission Tool Guide on the Provider Portal.

• Use IHAs as a tool to improve your Alliance Care-Based Incentive (CBI) All billing codes that qualify for IHAs also give you credit for the following CBI measure:
  • Child and Adolescent Well-Care Visits (3-21 years).
• IHA visits are an opportune time to complete preventative health screenings, including:
  • Cervical cancer screening.
  • Diabetic health screenings.
  • Immunizations
  • Depression screening.
• Talk to your patients about your clinic’s scheduling availability (e.g. same-day appointments, after hours availability, etc.) and what to do when they get sick.
• Provide patients with resources for medical advice after hours, including the Alliance Nurse Advice Line. Route after hours calls for Alliance members to the Alliance’s Nurse Advice Line at 844-971-8907.
• Refer Alliance members to Care Management services, including Complex Case Management and Care Coordination, by calling Case Management at 800-700-3874, ext. 5512.
• Refer Alliance members to Enhanced Care Management (ECM) Services and Community Supports through the Alliance Provider Portal, online referral on our website, or by phone at 831-430-5512.
• Alliance interpreting services are available to network providers:
  • Telephonic interpreting services are available to assist in scheduling members.
  • Face-to-face interpreters can be requested to be at the appointment with the member.

  For information about our Cultural and Linguistic Services Program, please call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].

• Refer patients who have transportation challenges to the Alliance’s Transportation Coordinator at 800-700-3874, ext. 5577. This service is not covered for non-medical locations or for appointments that are not medically necessary.

• APL 22-030 Initial Health Appointment
• APL 22-17 Primary Care Provider Site Reviews: Facility Site Review and Medical Record Review
  • Medical Record Review (MRR) Standards
• Population Management Policy Guide