Diabetic HbA1c Poor Control >9% Tip Sheet

Incentives will be paid to the linked primary care provider (PCP) on an annual basis, following the end of Quarter 4. For additional information, refer to the CBI Technical Specifications.

Members who do not have a diagnosis of diabetes in any setting during the measurement year or the year prior and who had a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or year prior.

Members in hospice or receiving hospice services or palliative care during the measurement year.

Members who died any time during the measurement year (CBI 2024 only).

Members 66 years of age and older as of December 31 of the measurement year with frailty and advanced illness:

• At least two indications of frailty with different dates of service during the measurement year (one encounter for CBI 2023 only).
• Any of the following during the measurement year or year prior to the measurement period (count services that occur over both years):
  • At least two outpatient, observation, ED visits, e-visits or virtual check-ins, non-acute inpatient encounter, or nonacute inpatient discharge on a different date of service (DOS), with an advanced illness diagnosis. Visit types must be the same for the two visits.
  • At least one acute inpatient encounter or one acute inpatient discharge with an advanced illness diagnosis.
  • A dispensed dementia medication.

CPT Codes: 83036, 83037 (Non Medi-Cal benefit code)

LOINC Codes: 17856-6, 4548-4, 4549-2, 96595-4

CPT Category II codes are optional tracking codes that can be used for performance measurement, here defining the HbA1c range. They may not be used as a substitute for Category I codes.

Data for this measure is collected using claims, laboratory data, DHCS FFS encounter claims, and provider data submissions via the 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 diabetes care quality report or your Care-Based Incentives Measure Details report on the Provider Portal and compare to EHR/paper charts.

This measure allows providers to submit HbA1c test results 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.

HbA1c Testing

• Perform A1C test every 3 months in patients whose therapy has changed or who are not meeting glycemic goals (≥0 HbA1c).
• Set appropriate individualized A1C goals based on relevant comorbidities, demographic factors and other considerations.
• Point-of-care testing for A1C provides the opportunity for more timely treatment changes.

Health Education

• Recommend lifestyle changes as appropriate (e.g. stress management, exercise and better eating habits).
• Enroll members into Alliance Health Education and Disease Management Programs using the Health Education and Disease Management Program Referral Form.
  • The Live Better with Diabetes program covers diabetes education for all ages and provides tools for diabetes management.
  • The Diabetes Self-Management Education program (DSME) connects members diagnosed with diabetes with up to 20.5 hours of education during the initial 12 months following the diagnosis. The program also includes up to two hours of follow-up each year with pre-approved education providers (i.e. Certified Diabetes Educators).
  • The Diabetes Prevention Program (CDC-DPP) is an evidence-based curriculum for members diagnosed with pre-diabetes that connects members to lifestyle coaches.
  • Healthier Living Program (HLP), is a six-week series of self-management workshops that focus on health, wellness and problems that are common to individuals suffering from any chronic conditions.

Alliance Resources

• 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.

Clinic Education

• Pharmacist-Led Academic detailing (PLAD) is an effective, multi-faceted educational program designed to support Alliance primary care clinicians and their patients. We aim to improve the quality of care provided to patients with diabetes by collaborating with clinicians to implement evidence-based pharmacologic clinical guidelines in diabetes care management. The interactive sessions with clinicians are tailored to their specific needs and interests, making it a personalized and effective approach. Sessions involve interactive discussions, case studies, and useful tools for implementing best practices in the clinical setting. For more information, please email [email protected] and include the phrase “Pharmacist-Led Academic Detailing” in the subject line.