QEM Services definition

QEM Services means Qualified Evaluation & Management (QEM) services identified by the Healthcare Common Procedure Coding System (HCPCS) codes listed in Table 1.2 of this Appendix B.

QEM Services means Qualified Evaluation & Management (QEM) services identified by the Healthcare Common Procedure Coding System (HCPCS) codes listed in Table 1.2 of this Part 1 of Appendix B.

Examples of QEM Services in a sentence

• The weighted allowable charge for all QEM Services that the Beneficiary received from a provider or supplier not included on the Participant List for the relevant Performance Year.

• If less than 10% of the weighted allowable charges are for QEM Services furnished by Primary Care Specialists, then Beneficiary alignment is based on the weighted allowable charges for QEM Services furnished by Non-Primary Care Specialists.

• In the case of a tie in the dollar amount of the weighted allowable charges for QEM Services furnished to a Beneficiary by two or more providers or suppliers, the Beneficiary will be aligned to the provider or supplier from whom the Beneficiary most recently obtained a QEM Service.

• Care Specialists If 10% or more of the weighted allowable charges are for QEM Services furnished by Primary Care Specialists, then Beneficiary alignment is based on the weighted allowable charges for QEM Services furnished by Primary Care Specialists.

• For purposes of financial settlement of Shared Savings and Shared Losses, Beneficiaries will also be excluded from the population of Initiative Beneficiaries retroactive to the start of the Performance Year if, during the Performance Year, at least 50% of QEM Services received by the Beneficiary were furnished by providers or suppliers practicing outside the ACO Service Area.

• A Beneficiary is aligned to the ACO for a Base Year if the Beneficiary received the plurality of QEM Services during the applicable Base Year Alignment Period from an Initative Professional included on the Participant List for the relevant Performance Year.

• Beneficiaries are similarly aligned to the ACO for each Base Year on the basis of each Beneficiary’s receipt of QEM Services from an Initiative Professional during the Base Year Alignment Period using the alignment algorithm described in Section II.C of this Appendix.

• Beneficiaries are aligned to the ACO for each Performance Year on the basis of each Beneficiary’s receipt of QEM Services from an Initiative Professional during the Performance Year Alignment Period using the alignment algorithm described in Section II.C of this Appendix.

• A Beneficiary is aligned to the ACO for a Performance Year if the Beneficiary received the plurality of QEM Services during the applicable Performance Year Alignment Period from an Initative Professional included on the Participant List for that Performance Year.

• Only those claims for QEM Services that are identified as being furnished by Primary Care Specialists or, if applicable, Non-Primary Care Specialists will be used in Beneficiary alignment determinations.