Initial Health Appointment Tip Sheet

Incentives are paid to the linked primary care provider (PCP) on an annual basis, following the end of quarter four. For additional information, refer to the CBI Technical Specifications.

• Administrative members at the end of the measurement period.
• Dual coverage members within 120 days after enrollment.

All IHA visits require a:

• Comprehensive health history.
• Member risk assessment,* which includes at least one of the following risk assessment domains (separate from mental and behavioral assessments):
  • Health risk assessment (HRA).
  • Social determinants of health (for example, housing instability, functioning, quality of life outcomes and risk, utility needs, interpersonal safety, etc.). Eligible tools include:
    • PRAPARE® Screening Tool.
    • Social Needs Screening Tool – short version.
    • ARC Health-Related Social Needs Screening Tool.
    • Health Leads Social Screening Toolkit.
  • Cognitive health assessment – Dementia Care Aware.
  • Adverse Childhood Experiences screening.
• Physical exam.
• Mental status exam and behavioral assessment* (for example, depression, anxiety, drug and alcohol screening).
• Dental assessment. A review of the organ systems that include documentation of “inspection of the mouth” or “seeing dentist” meets the criteria.
• Preventive screening (for example, breast cancer, cervical cancer, colorectal cancer, diabetic, cardiovascular disease including high blood pressure and STD screening).
• Health education and anticipatory guidance, age-specific preventive screens including vaccines. (for example, safety, obesity, tobacco use, immunizations).
• Diagnoses and a plan of care.

*Screenings may be completed over many visits.

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

1. Contact 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. Go to “Linked Member List” and click on the “New Members/120 Day IHA” tab.
     2. Review the list and remove patients who already completed their IHA visit.
   • Assign a person (office manager or call center manager) to ensure new members are contacted.
   • Attempt to contact members at least three times. Document if you made at least three unsuccessful attempts (two phone calls and one 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. Prepare for IHA visits
   • If using an EHR system:
     • Create a template for IHAs. Required elements include:
       • Comprehensive history.
       • Physical, risk assessment and mental status exam.
       • Individual health education.
       • Behavioral assessment.
       • Diagnoses.
       • Plan of care.
   • If using paper records, create new patient paperwork packets specifically for IHAs.
   • IHAs require an extended visit. Establish a routine to schedule IHAs when the most support staff is available or limit the number of IHAs scheduled per hour.
   • To help IHA visits go smoothly:
     • Call patients in advance and complete their initial health history and SHA form over the phone or via the 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. Ensure accurate billing
   • Ask a billing team member to 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 under Coding Requirements).

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

The Alliance implemented the IHA dummy code combination to allow providers to report certain exemptions to perform the IHA. These exemptions include the IHA completed 12 months prior to enrollment, members who refuse an IHA, a missed appointment or an attempt to schedule a member at least three times for their IHA appointment.

IHA 12 months prior to Medi-Cal enrollment
If the member’s plan PCP did not perform the IHA within the last 12 months because it was performed by another provider, the PCP must record that the findings were reviewed and updated in the member’s medical record.

For members who are currently established patients and then become newly eligible (this includes having other health coverage prior), the provider must document that the member received an IHA that meets all requirements in the member’s medical record.

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

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

Three attempts to schedule
Providers can make three documented, unsuccessful scheduling attempts (two telephone attempts and one written attempt or vice versa) to qualify for the measure.

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

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

Members are compliant for an IHA, with the use of the dummy code, if the provider uploaded to the Data Submission Tool on the Alliance Provider Portal. We no longer accept dummy code submissions from claims.

Note: IHA visit notes should be maintained in the member’s medical record and are audited as part of the routine Facility Site Review (FSR) requirements. The Alliance performs biannual audits to ensure IHA dummy codes are submitted appropriately.

Records are reviewed:

• To ensure the billed CPT & ICD-10 codes are supported by the documentation.
• Against current DHCS All Plan Letters (APLs) guidance to ensure policy requirements are followed.

Data for this measure is 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. For example, download the monthly Newly Linked Members and 120-Day Initial Health Assessment reports on the Provider Portal and compare it to your EHR/paper records.

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, 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) score. All billing codes that qualify for IHAs also give you credit for the following CBI measure:
  • Child and Adolescent Well-Care Visits (three to 21 years).
• IHA visits are an opportunity to complete preventive health screenings, including:
  • Cervical cancer screening.
  • Diabetic health screening.
  • Immunizations.
  • Depression screening.
• Talk to your patients about your clinic’s scheduling availability (same-day appointments, after-hour availability, etc.) and what to do when they get sick.
• Route after-hours calls from Alliance members to the Nurse Advice Line: 844-971-8907.

• Alliance Cultural and Linguistic Services are available to network providers.
  • Language Assistance Services – Request materials at 800-700-3874, ext. 5504.
  • Telephonic Interpreter Service – Directly access a telephonic interpreter 24 hours a day, 7 days a week.
  • Interpreter Services – Can be requested for the appointment with the member.
  • Virtual Remote Interpreter (VRI) Service – When an in-person interpreter might not be available or easy to access.
  • For information about the Cultural and Linguistic Services Program, call the Alliance Health Education Line at 800-700-3874, ext. 5580 or email us at [email protected].
• Alliance Enhanced Care Management (ECM) and Community Supports.
  • Refer Alliance members through the Alliance Provider Portal, email [email protected], mail or fax, or by phone at 831-430-5512.
  • For Complex Care Management and Care Coordination, call the Care Management team at 800-700-3874 (TTY: Dial 711).
• Alliance Transportation Services for patients with transportation challenges.
  • For non-emergency medical transportation (NEMT) services, call 800-700-3874, ext. 5640 (TTY: Dial 711).
  • For non-medical transportation (NMT) services, call 800-700-3874, ext. 5577 (TTY: Dial 711).
• APL 22-030 Initial Health Appointment – Department of Health Care Services (DHCS).
• APL 22-17 Primary Care Provider Site Reviews: Facility Site Review and Medical Record Review – DHCS.
• Population Health Management (PHM) Policy Guide – DHCS.
• Primary Care Provider-Medical Record Review (MRR) Standards – DHCS.