HEDIS Compliance Auditors
Health plans and physician organizations that report quality results in AMP Commercial HMO 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 AMP Commercial HMO. Use of an individual auditor or audit firm is a matter of organizational preference; any NCQA licensed auditor or audit firm is sufficient for AMP Commercial HMO.
Audit Review Guidelines
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 audit standards represent key processes involved in clinical data collection and reporting and include standards and assessments that apply to physician organizations that opt to self-report clinical data. HEDIS® is a registered trademark of the NCQA.
Value Set Directory
The MY 2018 AMP Program Manual and VSDs are required resources for California stakeholders participating in the Integrated Healthcare Association’s (IHA) AMP programs. The 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 AMP Program Manual to an electronic format, called Value Set Directories (VSDs) which are available free of charge to download from the NCQA website: MY 2018 Value Set Directory.
AMP Commercial HMO Results Questions and Appeals Period
Despite a thorough validation and quality assurance process, it is possible for discrepancies to occur in preliminary AMP Commercial HMO results. 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 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 results are finalized for use in public reporting, identifying Excellence in Healthcare, Bangasser Most Improved, and Top 10% award winners, and value based incentive payments.
Measurement Year 2017 Data File Layouts (FINAL)
Physician Organizations (Self-Reporting)
Physician Organizations (Non-Self Reporting - Advancing Care Information Participation)