Optum


December 2016
Closing Quality Gaps

Did you know...

  • There are only a few weeks left to close gaps in care for 2016
    • You are still in time to submit gap closure information received from diagnostics centers, specialist, and other care providers. About 4% of quality measures submitted for abstraction have not closed the quality gap because information from provider only contained evidence of referral (which does not actually close the gap).
    • 21% of quality measures submitted for abstraction have not closed the quality gap because the measure and/or screening information was not found in medical record. Amongst the measures with the most missing information are Diabetes Eye Exam, Colorectal Cancer Screening and Adult BMI.
    • There have been more than 5,000 records submitted for Colorectal Cancer Screening with either missing screening date or missing information on specific test type. Please review submitted documentation to ensure this information is included on your end of year submissions.

Please keep in mind...

  • Measure compliance for "Control Measures" such as Diabetes HbA1c control and Controlling Blood Pressure are based solely on the last reading of the year, there is still a chance to make an impact
    • About 13% of medical records submitted with evidence of a blood pressure reading, had results that were out of compliance and did not close the measure gap.
    • 18,000 submitted records for HbA1c screening and control, had only an indication of the member being referred for lab screening, without any results, and thus not closing the gap.
    • About 7,500 records submitted for both Diabetes HbA1c control and Controlling Blood Pressure measures contained information not legible for chart abstraction.

 Good news...

  • HEDIS is now accepting two additional screening types to test for colorectal cancer
    • In addition to accepting the following screening test for colorectal cancer:
      • FOBT during the measurement year
      • Flexible sigmoidoscopy during the measurement year or four years prior to measurement year
      • Colonoscopy during the measurement year or nine years prior to measurement year
    • NCQA will now also accept:
      • CT colonography during the measurement year or four years prior to measurement year
      • FIT-DNA (Cologuard) during the measurement year or two years prior to measurement year

 Reminder…

As you continue to prospectively complete your 2016 forms, there are some important dates to remember:

  • 2016 HQPAFs/PAFs expire on 12/31/2016
  • Forms can be submitted through 3/1/2017 with a 2016 Date of Service (DOS)
  • Rejected forms can be submitted through 5/1/2017 with corrections and a 2016 DOS

The 2016 HQPAFs/PAFs will be available via OPAF and InSite until the transition to the 2017 Program year which is anticipated on or about 2/13/17. You can continue to use the 2016 HQPAFs/PAFs to submit 2016 end of year patient encounters. Do not use the 2016 HQPAFs/PAFs to submit 2017 DOS as 2016 HQPAFs/PAFs submitted with a 2017 DOS will be rejected. Please hold 2017 encounter submissions until the 2017 forms are available in mid-February.
Please be advised that over the next three months, providers will need to submit an Account Setup Form (ASF), W9, and complete their direct deposit enrollment; if they have not already done so.

  • The ASFs, W9s, and direct deposit enrollment are due by 3/1/2017.
  • Failure to comply with these requirements will result in automatic forfeiture of reimbursement for all 2015 and 2016 PAFs/HQPAFs. 

Note: submission of an ASF, W9, and direct deposit enrollment is not required for any groups that are already receiving PAF/HQPAF reimbursement. This message only pertains to those who have PAFs/HQPAFs pending payment.

  • If any provider groups would like to know if they have pending payments, they should contact their Healthcare Advocate or call the Optum Provider Support Center at 1-877-751-9207.

If you have any questions about the PAF or HQPAF programs, please contact your local Optum Healthcare Advocate or the Optum Provider Support Center between 6:30 a.m.–4:30 p.m. PST, Monday–Friday, at 1-877-751-9207 or email us here.

Thank you again for your participation in the Optum Patient Assessment Form (PAF) and the Healthcare Quality Patient Assessment Form (HQPAF) programs.

As of October 1st 2016, we will no longer offer SFTP as an option to submit your Healthcare Quality Patient Assessment Forms/ Patient Assessment Forms (HQPAF/PAF). The last day to use the SFTP for submission will be September 30th, 2016.

Effective immediately, we encourage you to use our new HQPAF/PAF Uploader; an easier and faster submission method. The HQPAF/PAF Uploader requires less time and effort than preparing and submitting documentation via mail or fax.

The HQPAF/PAF Uploader was developed to provide an interface that allows multiple users to securely submit HQPAFs/PAFs without issue of failed delivery or suspended access. The HQPAF/PAF Uploader:

  • does not require any user credentials
  • complies with all HIPAA guidelines to protect your practice and your patient’s personal data
  • allows anyone in your office to access the site and upload documentation
  • securely transmits directly to Optum

To get started, please visit: optumupload.com.


For additional information as well as publications and products available for HEDIS®, please visit the National Committee for Quality Assurance (NCQA) website at ncqa.org.

For additional information about the Medicare Advantage Five-Star Quality Rating System, please refer to: http://go.cms.gov/partcanddstarratings.