Final Data File Layouts (Measurement Year 2016)
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)
Physician Organizations (Non-Self Reporting)
Despite a thorough validation and quality assurance process, it is possible for discrepancies to occur in VBP4P Preliminary Reports. Therefore, there is a formal appeals process for both physician organizations and health plans to request changes. The appeals process begins the day the preliminary quality results are released and continues for 21 days. After the 21-day review period, the VBP4P Appeals Committee will make final decisions regarding appeals. The Appeals Committee is comprised of three health plan representatives, three phyisician organization representatives, and one at-large member, who often also support the existing VBP4P program and/or participate on VBP4P governance or technical committees. Following the Appeals Hearing, POs will be notified of the status of their appeal and instructed to make any changes or resubmissions (if necessary) before the preliminary quality results are finalized for the measurement year.
The appeals period for Measurement Year 2016 is scheduled for May 25–June 15, 2017. Instructions and forms for filing an appeal will be posted on this webpage prior to the opening of the appeals period, and communicated broadly to VBP4P stakeholders.
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.
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.
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.