Quality Eligibility Dictionary

[andrewallenbruce]

Top Level

year = 'Year',
npi = 'National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers by CMS',
npi_type = 'Numeric code describing the type of provider that is is represented by the National Provider Identifier (NPI)',
first = 'Provider first name',
middle = 'Provider middle name',
last = 'Provider last name',
specialty_description = 'Provider specialty',
specialty_type = 'Provider specialty type',
specialty_category = 'Provider specialty category',
specialty_code = 'Provider specialty code, two-character code for a clinicians occupation',
first_approved_date = 'The first date an enrollment was approved for this NPI across all enrollments',
years_in_medicare = 'Number of years since first_approved_date',
pecos_year = 'Year of enrollment into Provider Enrollment, Chain and Ownership System (PECOS)',
newly_enrolled = 'Is provider newly enrolled?',
qp_status = 'Qualifying APM Participant. Allowed values: Y, N, P, Q, R.',
is_maqi = 'Has clinician been granted a MAQI Demonstration Waiver?',
qp_score_type = 'The category in which an APM participant is QP. Allowed values: MI, ME, AE, AT, AI.',
amsMipsEligibleClinician = 'MIPS Eligible Clinician (EC) Indicator',
organizations = NA,
prvdrOrgName = 'If provider is a practice, rather than an individual, practice name will be displayed.',
isFacilityBased = 'True if the threshold of facility based encounters is met',
address = 'Uppercased street number, street name, and street suffix abbreviation. Can include secondary unit information such as suite.',
city = 'Address city',
state = 'Nine digit zip code',
zip = 'Uppercased state abbreviation',
hospitalVbpName = 'Facility name within the Hospital Value-Based Purchasing Program',

Individual Scenario

  individual = dplyr::tibble(
    aciHardship = 'True if there is an approved ACI Hardship Exemption application',
    aciReweighting = 'True if the group meets the conditions necessary for ACI Reweighting',
    aggregationLevel = 'Allowed values: 1, 2',
    ambulatorySurgicalCenter = 'True if clinician met the threshold for being designated as an Ambulatory Surgical Center (ASC). ASCs provide surgery without an overnight hospital stay.',
    eligibilityScenario = 'Number reflecting the eligibility profile which is used to manage user interface messaging. This value has no impact on eligibility and is simply used to control UI content.',
    extremeHardship = 'True if Extreme and Uncontrollable Circumstance Exemption credit has been received',
    extremeHardshipEventType = 'Type of extreme hardship event',
    extremeHardshipReasons = NA,
    quality = 'True if extreme hardship exemption due to quality',
    improvementActivities = 'True if extreme hardship exemption due to improvement activities',
    aci = 'True if extreme hardship exemption due to aci',
    cost = 'True if extreme hardship exemption due to cost',
    extremeHardshipSources = NA,
    Items = 'Extreme hardship reporting source. Allowed values: auto-fema, manual, auto-covid.',
    hasHospitalVbpCCN = 'True if TIN-NPI has a Hospital Value-Based CCN',
    hasPaymentAdjustmentCCN = 'True if TIN-NPI has a Payment Adjustment CCN',
    hospitalBasedClinician = 'True if clinician met the threshold of hospital-based expenditures',
    hospitalVbpName = 'Facility name within the Hospital Value-Based Purchasing Program',
    hospitalVbpScore = 'Hospital Value-Based Purchasing Program score',
    hpsaClinician = 'True if clinician has at least one claim with an HPSA designation',
    iaStudy = 'True if Improvement Activities Study data is present',
    isEligible = NA,
    individual = 'flag',
    group = 'flag',
    mipsApm = 'flag',
    virtualGroup = 'flag',
    isFacilityBased = 'True if the threshold of facility based encounters is met',
    isOptedIn = 'Whether the entity has opted in or opted out. Will be null if no decision has been made.',
    isOptInEligible = 'Whether the entity is eligible to opt in.',
    lowVolumeServices = 'Number of claim lines counted toward low volume service threshold',
    lowVolumeStatusReasons = NA,
    lowVolumeSwitch = 'Fell below the low volume threshold',
    lowVolStusRsnCd = 'If lowVolumeSwitch is true, this array will contain the reasons for the status. Possible values: BENE: Clinician’s number of unique beneficiaries fell below the low volume threshold. CHRG: Clinician’s Part B expenditures fell below the low volume threshold. SRVC: Clinician’s low volume services fell below the low volume threshold. BOTH: Both the clinician’s number of unique beneficiaries and Part B expenditures fell below the low volume threshold. BENE_SRVC: Both the clinician’s number of unique beneficiaries and low volume services fell below the low volume threshold. CHRG_SRVC: Both the clinician’s Part B expenditures and low volume services fell below the low volume threshold. ALL: Clinician’s number of unique beneficiaries, Part B expenditures, and low volume services fell below the low volume threshold.',
    lowVolStusRsnDesc = 'Description of lowVolStusRsnCd',
    mipsEligibleSwitch = 'Clinician is a provider type that is eligible for Merit-Based Payment Incentive System (MIPS)',
    nonPatientFacing = 'True if patient-facing encounters met the encounter threshold',
    optInDecisionDate = 'The date of the opt-in decision.',
    ruralClinician = 'True if clinician has at least one claim with a zip code designated as rural',
    smallGroupPractitioner = 'True if 15 or fewer clinicians bill under the group')

Group Scenario

  group = dplyr::tibble(
    aciHardship = 'True if there is an approved ACI Hardship Exemption application',
    aciReweighting = 'True if the group meets the conditions necessary for ACI Reweighting',
    aggregationLevel = 'Allowed values: 1, 2',
    ambulatorySurgicalCenter = 'True if clinician met the threshold for being designated as an Ambulatory Surgical Center (ASC). ASCs provide surgery without an overnight hospital stay.',
    eligibilityScenario = 'Number reflecting the eligibility profile which is used to manage user interface messaging. This value has no impact on eligibility and is simply used to control UI content.',
    extremeHardship = 'True if Extreme and Uncontrollable Circumstance Exemption credit has been received',
    extremeHardshipEventType = 'Type of extreme hardship event',
    extremeHardshipReasons = NA,
    quality = 'True if extreme hardship exemption due to quality',
    improvementActivities = 'True if extreme hardship exemption due to improvement activities',
    aci = 'True if extreme hardship exemption due to aci',
    cost = 'True if extreme hardship exemption due to cost',
    extremeHardshipSources = 'Extreme hardship reporting source. Allowed values: auto-fema, manual, auto-covid.',
    hasHospitalVbpCCN = 'True if TIN-NPI has a Hospital Value-Based CCN',
    hasPaymentAdjustmentCCN = 'True if TIN-NPI has a Payment Adjustment CCN',
    hospitalBasedClinician = 'True if clinician met the threshold of hospital-based expenditures',
    hospitalVbpName = 'Facility name within the Hospital Value-Based Purchasing Program',
    hospitalVbpScore = 'Hospital Value-Based Purchasing Program score',
    hpsaClinician = 'True if clinician has at least one claim with an HPSA designation',
    iaStudy = 'True if Improvement Activities Study data is present',
    isEligible = NA,
    group = 'flag',
    mipsApm = 'flag',
    virtualGroup = 'flag',
    isFacilityBased = 'True if the threshold of facility based encounters is met',
    isOptedIn = 'Whether the entity has opted in or opted out. Will be null if no decision has been made.',
    isOptInEligible = 'Whether the entity is eligible to opt in.',
    lowVolumeServices = 'Number of claim lines counted toward low volume service threshold',
    lowVolumeStatusReasons = NA,
    lowVolumeSwitch = 'Fell below the low volume threshold',
    lowVolStusRsnCd = 'If lowVolumeSwitch is true, this array will contain the reasons for the status. Possible values: BENE: Clinician’s number of unique beneficiaries fell below the low volume threshold. CHRG: Clinician’s Part B expenditures fell below the low volume threshold. SRVC: Clinician’s low volume services fell below the low volume threshold. BOTH: Both the clinician’s number of unique beneficiaries and Part B expenditures fell below the low volume threshold. BENE_SRVC: Both the clinician’s number of unique beneficiaries and low volume services fell below the low volume threshold. CHRG_SRVC: Both the clinician’s Part B expenditures and low volume services fell below the low volume threshold. ALL: Clinician’s number of unique beneficiaries, Part B expenditures, and low volume services fell below the low volume threshold.',
    lowVolStusRsnDesc = 'Description of lowVolStusRsnCd',
    mipsEligibleSwitch = 'Clinician is a provider type that is eligible for Merit-Based Payment Incentive System (MIPS)',
    nonPatientFacing = 'True if patient-facing encounters met the encounter threshold',
    optInDecisionDate = 'The date of the opt-in decision.',
    ruralClinician = 'True if clinician has at least one claim with a zip code designated as rural',
    smallGroupPractitioner = 'True if 15 or fewer clinicians bill under the group')

APMS Scenario

  APMS = dplyr::tibble(
    entityName = 'Official name of the Organization',
    lvtFlag = 'Indicates if the APM Entity is below the low volume threshold',
    lvtPayments = 'Total aggregated expenditures of the APM Entity',
    lvtPatients = 'Total number of unique patients of the APM Entity',
    lvtSmallStatus = 'Whether the APM Entity has Small Practice status',
    lvtPerformanceYear = 'The relevant year for the APM dataset',
    apmId = 'Unique combination of characters, numbers or symbols that are assigned by CMS Model operations to support establishing the identity of an APM Program',
    apmName = 'Formal label by which the APM Program is identified',
    subdivisionId = 'Identifier for a specific grouping within the APM Program for QPP purposes',
    subdivisionName = 'Identification label for the QPP Subdivision',
    advancedApmFlag = 'APMs that require MIPS comparable measures, use of CEHRT, and more than nominal downside risk. Eligible clinicians that participate in Advanced APMs are able to become QPs and receive a 5% bonus and be exempt from MIPS.',
    mipsApmFlag = 'APMs that already assess participants on cost and quality under the terms of the APM.',
    providerRelationshipCode = 'Identifier of the APM Program Provider Relationship Type',
    qpPatientScores = 'ae, ai, at, me, mi',
    qpPaymentScores = 'ae, ai, at, me, mi',
    complexPatientScore = 'Composite Complex-Patient Score calculated by a combination of the dual eligibility ratio and the Hierarchical Conditions Category (HCC) risk score; max 5.00, min 0.00. The value of this field will be null when the requestor is not authorized to view data for the associated practice/TIN.',
    finalQpcScore = NA,
    extremeHardship = 'True if Extreme and Uncontrollable Circumstance Exemption credit has been received',
    extremeHardshipReasons = NA,
    quality = 'True if extreme hardship exemption due to quality',
    improvementActivities = 'improvementActivities',
    aci = 'True if extreme hardship exemption due to aci',
    cost = 'True if extreme hardship exemption due to cost',
    extremeHardshipEventType = 'Type of extreme hardship event',
    extremeHardshipSources = 'Extreme hardship reporting source. Allowed values: auto-fema, manual, auto-covid.',
    isOptedIn = 'Whether the entity has opted in or opted out. Will be null if no decision has been made.')

Virtual Groups Scenario

  virtualGroups = dplyr::tibble(
    virtualGroupIdentifier = 'Masked Virtual Group identifier.',
    claimsTypes = 'Type of claims made by this Virtual Group.',
    lowVolumeStatusReasons = NA,
    lowVolumeSwitch = 'Fell below the low volume threshold',
    lowVolStusRsnCd = 'If lowVolumeSwitch is true, this array will contain the reasons for the status. Possible values: BENE: Clinician’s number of unique beneficiaries fell below the low volume threshold. CHRG: Clinician’s Part B expenditures fell below the low volume threshold. SRVC: Clinician’s low volume services fell below the low volume threshold. BOTH: Both the clinician’s number of unique beneficiaries and Part B expenditures fell below the low volume threshold. BENE_SRVC: Both the clinician’s number of unique beneficiaries and low volume services fell below the low volume threshold. CHRG_SRVC: Both the clinician’s Part B expenditures and low volume services fell below the low volume threshold. ALL: Clinician’s number of unique beneficiaries, Part B expenditures, and low volume services fell below the low volume threshold.',
    lowVolStusRsnDesc = 'Description of lowVolStusRsnCd',
    beneficiaryCount = 'Number of patients used to determine low volume threshold status',
    allowedCharges = 'Billing amount used to determine low volume threshold status',
    hospitalVbpName = 'Facility name within the Hospital Value-Based Purchasing Program',
    isFacilityBased = 'True if the threshold of facility based encounters is met',
    hospitalVbpScore = 'Hospital Value-Based Purchasing Program score')

Special Scenario

  specialScenario = dplyr::tibble(
    aciReweighting = 'True if the group meets the conditions necessary for ACI Reweighting',
    nonPatientFacing = 'True if patient-facing encounters met the encounter threshold',
    ruralClinician = 'True if clinician has at least one claim with a zip code designated as rural',
    hpsaClinician = 'True if clinician has at least one claim with an HPSA designation',
    hospitalBasedClinician = 'True if clinician met the threshold of hospital-based expenditures',
    ambulatorySurgicalCenter = 'True if clinician met the threshold for being designated as an Ambulatory Surgical Center (ASC). ASCs provide surgery without an overnight hospital stay.',
    aciHardship = 'True if there is an approved ACI Hardship Exemption application',
    iaStudy = 'True if Improvement Activities Study data is present',
    smallGroupPractitioner = 'True if 15 or fewer clinicians bill under the group',
    extremeHardship = 'True if Extreme and Uncontrollable Circumstance Exemption credit has been received',
    extremeHardshipReasons = NA,
    quality = 'True if extreme hardship exemption due to quality',
    improvementActivities = 'improvementActivities',
    aci = 'True if extreme hardship exemption due to aci',
    cost = 'True if extreme hardship exemption due to cost',
    extremeHardshipEventType = 'Type of extreme hardship event',
    extremeHardshipSources = 'Extreme hardship reporting source. Allowed values: auto-fema, manual, auto-covid.'))

Originally posted by @andrewallenbruce in andrewallenbruce/provider#61

[andrewallenbruce]

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