Data Collection & Submission

Value Based P4P Results Questions and Appeals Period

Despite a thorough validation and quality assurance process, it is possible for discrepancies to occur in VBP4P preliminary quality resutls. Therefore IHA relies on a formal review process, the Questions and Appeals Period, to allow both participating physician organizations and health plans to request more information about their preliminary results and to request an appeal for corrections before results are finalized for the measurement year. The appeals period begins the day the preliminary quality results are released and continues for 21 days. After the 21-day review period, submitted appeals are reviewed and adjudicated on by an Appeals Panel. The Appeals Panel is comprised of program participants, including three health plan representatives, three physician organization representatives, and one at-large representative. Following deliberation by the Appeals Panel, POs are notified of the status of their appeal and instructed to make any necessary changes or resubmissions. Once this process is complete, preliminary quality results are finalized for use in public reporting, identifying Excellence in Healthcare and Bangasser Most Improved award winners, and value based incentive payments. The Questions and Appeals Period for Measurement Year 2016 is scheduled for May 25–June 15, 2017; further information and required forms are provided below.

Final Data File Layouts (Measurement Year 2016)

Health Plans

Health Plan Clinical Measure Data File Layout

Please note: for MY 2016, the combined commercial HMO and Medicare Advantage layout has been eliminated. Instead, health plans that are submitting results for both populations will submit separate files. As part of this change, all health plan unique IDs have been updated and are provided in Tab 1.
 

Physician Organizations (Self-Reporting)

Self-Reporting PO Clinical Measure Data File Layout (Final)
 

Physician Organizations (Non-Self Reporting)

e-Measure Data File Layout for Non-Self Reporting POs (Final)

HEDIS Compliance Auditors

Health plans and physician organizations that report quality results in Value Based Pay for Performance (VBP4P) must contract with a HEDIS compliance auditor.  The National Committee for Quality Assurance (NCQA) licenses individuals and organizations to conduct Healthcare Effectiveness Data and Information Set (HEDIS) Compliance Audits, including audits for VBP4P.  Use of an individual auditor or audit firm is a matter of organizational preference; any NCQA licensed auditor or audit firm is sufficient for VBP4P.

NCQA-Certified HEDIS Compliance Auditors

Licensed Organizations for HEDIS Compliance Audits

Audit Review Guidelines

VBP4P Audit Review standards are derived from NCQA's HEDIS Compliance Audit Standards, the foundation on which Certified HEDIS Compliance Auditors assess a health plan's ability to report HEDIS data accurately and reliably. The VBP4P audit standards represent key processes involved in VBP4P clinical data collection and reporting and include standards and assessments that apply to physician organizations that opt to self-report the P4P clinical data. HEDIS® is a registered trademark of the NCQA.

Audit Review Guidelines Measurement Year 2016

Value Set Directory

The MY 2016 P4P Manual and VSDs are required resources for California stakeholders participating in the Integrated Healthcare Association’s (IHA) California P4P program. The MY 2016 P4P Value Set Directory consists of an electronic Excel file that is sortable and provides an easy way to incorporate CPT®, ICD-9-CM, ICD-10-CM, ICD-10-PCS, POS, MS-DRG, HCPCS, LOINC, TOB and UB codes into your organization's data collection program – saving programming hours, eliminating the manual search for codes and reducing keying errors.  NCQA converts all code tables for the VBP4P Manual to an electronic format, called Value Set Directories (VSDs) which are available free of charge to download from the NCQA website: MY 2016 Value Set Directory.