3 Colo. Code Regs. § 702-4-2-96-7

Current through Register Vol. 47, No. 24, December 25, 2024

Section 3 CCR 702-4-2-96-7 - Patient Attribution

A. Carriers must provide a detailed description of the patient attribution methodology(ies) utilized in an APM for primary care services to all providers participating in the APM. This description must include, at a minimum:

1. Definitions of key terms used in the model, including but not limited to "prospective", "retrospective", or "hybrid"; and

2. The process(es) used to attribute adult and pediatric members, including newborns and infants, to a provider. This description must include, at a minimum:

a. How patient choice is prioritized;

b. If and how claims are used to determine a provider-patient relationship, including but not limited to:

(1) the look-back period for claims data that is included in the methodology;

(2) the type (e.g., wellness visit) or number of claims that are prioritized; and

(3) tie-breaker methodologies if different providers have an equal number or type of claims;

c. If and how geographic attribution is used;

d. Any other processes or methods, such as visit-based, that are utilized; and

e. Any members that are excluded from attribution.

B. Carriers must make available updated attribution lists, in a format that is easy to interpret and analyze, to providers no less frequently than on a quarterly basis.

C. Carriers must establish and maintain a process for providers to submit requests for misattributed patients to be added or removed from their attribution list (i.e., reattributed).

1. The process for submitting reattribution requests must be clearly communicated to the provider and must identify, at a minimum:

a. The appropriate mechanism(s) for submitting a request (e.g., phone, mail, or electronic);

b. A specific point of contact for attribution-related questions and issues; and

c. The information or documentation required to submit a request.

2. Carriers must establish a process that is clearly communicated to the provider about the regular review, no less than quarterly, of patient attribution lists and provider attribution requests.

3 CCR 702-4-2-96-7

46 CR 24, December 25, 2023, effective 1/30/2024