Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-37 - MANAGED CARE › Section 560-X-37-.09 - Attribution Under The Alabama Coordinated Health Network Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Under the
			 Alabama Coordinated Health Network (ACHN) Program, Medicaid recipients will be
			 attributed to Primary Care Physician (PCP) Groups based on the historical
			 visitation practices of the Medicaid recipient. Attribution is the process that
			 will be used to associate a Medicaid recipient to the PCP Group that provides
			 primary care to that recipient. Under the ACHN Program, PCP Groups will be
			 eligible to receive bonus payments based on having a completed ACHN PCP Group
			 Agreement with the Medicaid Agency, a PCP Network Participation Agreement with
			 an ACHN, and meeting participation requirements as identified in the
			 Participation Agreement; in addition to meeting quality measures, cost
			 effectiveness measures, and Patient Centered Medical Home Recognition. If a PCP
			 Group is eligible to receive bonus payments, the amount of the bonus payments
			 payable to a PCP Group will be determined by the number of recipients
			 attributed to the PCP Group. On a quarterly basis, the Medicaid Agency will
			 perform attribution for each Medicaid recipient under the ACHN Program in
			 accordance to the following process:
(a) The
			 Medicaid Agency will review the previous two (2) year history of doctor visit
			 utilization for each Medicaid recipient. Utilization will consist of preventive
			 visits and regular office visits. A PCP is defined, by specialty, as Family
			 Practice, Pediatricians, Internists, General Practitioners, FQHCs, RHCs, and
			 Nurse Practitioners /Physicians Assistants in a PCP Group. When in the best
			 interest of a patient (e.g., children with special health care needs), a
			 nontraditional PCP specialty may consider as a PCP. Physicians with other
			 specialties may be considered for PCP participation if willing to meet active
			 participation requirements. All other providers are deemed
			 specialists.
(b) Points will only
			 be awarded for claims that are in a paid status before the end of the
			 attribution run period.
(c) The
			 Medicaid Agency will review the previous twelve (12) month history of filled
			 prescriptions for chronic care conditions for each Medicaid
			 recipient.
(d) The point values
			 described below associated with the visits and prescriptions will be assigned
			 to the individual doctor that performed the service. The individual PCP scores
			 will be combined to form the PCP Group's total point score.
(e) PCP Groups will receive points based on
			 the number of preventive visits and regular office visits conducted by the PCP
			 Group. Preventive visits will receive a higher point value. Visits that have
			 occurred more recently will receive a higher point value. Visits with a PCP
			 will receive a higher point value than visits with a specialist.
(f) PCP Groups will receive points based on
			 the number of prescriptions filled for chronic care conditions. For the
			 purposes of this rule, prescriptions for chronic care conditions shall mean
			 more than one prescription filled for a chronic condition (e.g., asthma) and
			 must correspond to an office visit from the prescribing provider within the
			 previous two (2) years.
(g) The PCP
			 Group with the highest number of points will have the Medicaid recipient
			 attributed to that PCP Group. The Medicaid recipient must have been eligible
			 for the ACHN program for three (3) out of the previous twenty-four (24) months
			 to be attributed.
(h) If a
			 specialist group has the highest number of points, then the specialist group
			 will be attributed the Medicaid recipient; however, a specialist group shall
			 not be eligible to receive the bonus payments described above.