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2.
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The data for the incentive
calculation are extracted from the TRICARE Encounter Data (TED) Institutional
claims, TED-I, using the following criteria.
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a.
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Including TED-I claims:
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i.
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For network hospitals that
are eligible for the P-BMP incentive as indicated by the DHA Program
Integrity (PI) Office.
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ii.
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With admission dates in the
applicable incentive cycle described in Figure 29.B-1. |
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iii.
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For TRICARE deliveries based
on the Medicare Severity-Diagnosis Related Group (MS-DRG) as follows:
765-768, 774, and 775. See Addendum C for
MS-DRG value descriptions. |
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iv.
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For High-Risk TRICARE
deliveries based on the 2018 International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM) diagnosis code
series O09.XX.
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b.
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Excluding TED-I claims:
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i.
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For hospitals that are located
outside the 50 United States and the District of Columbia (DC).
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ii.
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For hospitals that are located
in the State of Maryland.
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iii.
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For Critical Access Hospitals
(CAH).
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iv.
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With any Other Health Insurance
(OHI).
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v.
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For Uniformed Services Family
Health Plan (USFHP) beneficiaries.
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3.
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The total allowed charges for
TRICARE maternity care services for each hospital will be calculated
by the Government as follows:
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a.
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Total allowed charges for TRICARE
deliveries equal to the sum of allowed charges on all maternity
care claims with MS-DRG 765-768, 774, 775 (or their successors if
the MS-DRGs are restructured and/or renumbered) and admission dates
in the applicable incentive cycle described in Figure 29.B-1. |
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b.
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Total allowed charges for High-Risk TRICARE
deliveries equal to the sum of allowed charges on all maternity
care claims with 2018 ICD-10-CM diagnosis code series O09.XX and
admission dates in the applicable incentive cycle described in Figure 29.B-1,
performed at facilities with the High-Risk Delivery tier
designation. |
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4.
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Based on the hospital’s values
in the data field named Maternity Care Value Indicator and High-Risk
Delivery Indicator published in the P-BMP report, and input
provided by DHA Program Integrity Office, the incentive payment
for each hospital will be calculated by the DHA Decision Support
Office as the percentage of total allowed charges for TRICARE maternity
care claims generated in Step 3 for each incentive cycle using the
following logic and formulas.
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a.
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Base incentive payment calculations:
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i.
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For hospitals with a Maternity
Care Value Indicator of 1, the incentive payment will be
1% of total allowed charges for TRICARE deliveries generated in
Step 3.
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ii.
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For hospitals with a Maternity
Care Value Indicator of 2, the incentive payment will be
2% of total allowed charges for TRICARE deliveries generated in
Step 3.
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iii.
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For hospitals with a Maternity
Care Value Indicator less than 1, the incentive payment will be
0% of total allowed charges (no incentive payment) for TRICARE deliveries
generated in Step 3.
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b.
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Additional incentive payment
calculations:
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i.
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For hospitals with a High-Risk
Delivery Indicator of 1, additional incentive payment will be
1% of allowed charges on High-Risk TRICARE deliveries generated
in Step 3.
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ii.
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For hospitals with a High-Risk
Delivery Indicator less than 1, incentive payment equals 0%
of allowed charges (no additional incentive payment) on High-Risk TRICARE
deliveries generated in Step 3.
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c.
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Total incentive payment calculations:
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The total incentive payment
for each hospital is equal to the total sum of base incentive payment
and additional incentive payment.
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-
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A Maternity Care Value
Indicator of 1 represents Value tier which indicates
that the hospital met the target for any three of the four core
metrics (as stated in Section 4, paragraph 4.2). |
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-
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A Maternity Care Value
Indicator of 2 represents High Value tier which
indicates that the hospital met the target for all four core metrics
(as stated in Section 4, paragraph 4.2). |
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-
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A High-Risk Delivery
Indicator of 1 represents High-Risk Delivery tier
which indicates that the hospital was Value or High
Value tier and also met the Leapfrog target for High-Risk Deliveries with
at least 50 very-low birth weight (VLBW) babies per year.
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-
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No incentive payments will
be made to hospitals who met two, one, or zero core metrics, or who
chose not to participate in the Leapfrog Hospital Survey (or who
are rated “not applicable” by Leapfrog), regardless of whether they
met the Leapfrog target for High-Risk Deliveries.
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