Best Practice – Professional Organization Activity

Data Submission / Review Form

For Use with

Performance in Practice (PIP) / Performance Improvement Module (PIM) / METRIC Module or NCQA Physician Recognition Submissions Only

Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______Initiative Subject: ______

Practice NPI: ______

(Required: Please accurately complete your 10-digit #)

Office Contact Name: ______Title: ______

Phone Number: (_____) ______-______Ext.______

Please choose one submission type: PIP/PIM/METRIC Modules * or

NCQA Physician Recognition *

Highmark accepts in its QualityBLUE program:

·  The American Board of Family medicine (ABFM) Performance in Practice (PIP) Module

·  The American Board of Pediatrics (ABP) Performance in practice (PIP) activities

·  The American Board of Internal Medicine (ABIM) Maintenance of Certification Practice Improvement Modules (PIMs)

·  The American Academy of Family Physicians (AAFP) METRIC modules, and The National Committee for Quality Assurance (NCQA) Physician Recognition Programs

NOTE:

î Complete only one form per NPI / Practice

î Submissions with incomplete or erroneous information will delay review of your submission by the QualityBLUE Submission Committee and could affect your QualityBLUE score.

Highmark is a registered mark of Highmark Inc. Blue Shield, and the Shield symbols are registered service marks, and QualityBLUE is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______Initiative Subject: ______

Implementation activities are reviewed quarterly. The submissions must be postmarkED on or before the indicated quarterly deadline:

November 1 for 1st Quarter

February 1 for 2nd Quarter

May 1 for 3rd Quarter

August 1 for 4th Quarter

Additional Guidelines:

·  To obtain the five points, all physicians in your practice must participate in an activity as listed above. You must submit documentation for each physician in your practice who participated in any of these programs.
·  Photocopy or obtain proof documents (e.g., ABP’s Program for Maintenance of Certification (MOC) in Pediatrics® Activity Completion Report, AAFP’s METRIC Certificate, NCQA’s Physician Recognition Notification, etc.), staple the documentation to this form, and submit as usual. Be sure to complete all of the practice information at the top of the form.
·  Highmark will award the five points on an annual basis. To maintain the five points for Best Practice Initiative in QualityBLUE, you will be required to submit updated documentation every 12 months showing that the physicians in your practice completed a new activity as listed above or an office-based Best Practice. Updated documentation must be received and approved prior to the end of the 12-month period for which the previously awarded QualityBLUE points were applicable.
·  A practice cannot obtain partial credit for incomplete PIPs, PIMs, METRIC modules or NCQA Physician Recognition Programs. Please submit only the final proof documentation you receive or obtain from ABFM, ABP, ABIM, AAFP or NCQA.
·  Multi-specialty groups should submit ABIM, ABP, MOC, as documentation of PIP/PIM completion, or METRIC Certificates for Family Physicians in the practice, if there are modules in both programs for the same diagnosis. Highmark will accept any PIM completed individually or as a group.

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Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______Initiative Subject: ______

Required: Affiliated Physicians and Certification

Please list each affiliated physician and indicate whether certificate is attached.
NOTE:
If additional physicians need to be listed, please attach a separate page. / List each affiliated physician within the practice / Certificate Attached
YES / NO
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *
Physician Name: ______ / * / *


Required: Please indicate the total # of physicians within practice: ______

Please indicate the total # of certifications attached: ______

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Date Submitted to Highmark: ____/____/____

Practice or PBIP Name: ______Initiative Subject: ______

Faxes will not be accepted. Please mail this entire form with attachments to:

Highmark Blue Shield

QualityBLUE Submission Review Committee

P.O. BOX 535098

Pittsburgh, PA 15253-5098

QualityBLUE Submission Review Results – Highmark use only

Date Received by Highmark ____/____/____

Best Practice
Activities Reviewed / Points Assigned / Approved / Not Approved / Review Date / Committee Signature
PIP/PIM/METRIC Modules / 15
NCQA Physician Recognition / 15

Additional Committee Notes:

______
______

Highmark Blue Shield V2.0 10/08 Page 1 of 4

Best Practice Prof Org Activity Submission Form