PA Medicaid Provider Guidelines

Reference: “Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.

Found April 2014 Draft Needs Assessment Report for Potential Update of the Expert Panel Report 3 (2007)
https://www.nhlbi.nih.gov/files/docs/resources/lung/NHLBAC-Asthma-WG-Report.pdf

Clinical Indicators:

1. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year.
   Medicaid ages: 5-64
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications AMR)
2. The percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
   • The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
   • The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications - MMA)

Links:

• National Asthma Education and Prevention Program Expert Panel Report

Reference: October 2011 American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

Clinical Indicators:

1. The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed.
   
   Two rates are reported:

• Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.
• Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of
  the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, ADD)

Links:

• AAP Practice Guideline

Reference: The Global Initiative for Chronic Obstructive Lung Disease Guideline was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World Health Organization in 1998.

From the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019.

Clinical Indicators:

1. Percentage of members 40 years and older with a new diagnosis of COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPR)
2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event. (Source: HEDIS® 2019, Vol. 3, Technical Specifications, PCE)
3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed appropriate medications, and who were dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PCE)

Links:

• GOLD Reports

Reference:

1. 2013 ACC/AHA Guideline on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
2. 2013 ACCF/AHA Guideline for the Management of Heart Failure
3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary & Other Atherosclerotic Vascular Disease: 2011 Update
4. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Clinical Indicators:

1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PBH)
2. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who:
   • Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
   • Met statin adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPC)
3. The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure was adequately controlled during the measurement year <140/90.

Links:

• Treatment of Blood Cholesterol
• Guideline for the Management of Heart Failure
• Secondary Prevention and Risk Reduction for Coronary and other Atherosclerotic Vascular Disease
• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Reference: Centers for Disease Control and Prevention-Childhood Overweight and Obesity

AAP Updates Recommendations on Obesity Prevention: Its's Never Too Early to Begin Living a Healthy Lifestyle

American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Patients with Obesity 2016 

Journal of Clinical Endocrinology and Metabolism, Pediatric Obesity-=Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline

Clinical Indicators:

1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (ages 3-17)

The percentage of members 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and had evidence of following during the measurement year:

• BMI percentile documentation*
• Counseling for nutrition
• Counseling for physical activity

 *           Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value.

  (HEDIS® 2019, Vol. 2, Technical Specifications – WCC)

Links:

• CDC

Reference: "Cystic Fibrosis Foundation:
Clinical Care Guidelines

Cystic Fibrosis pulmonary guidelines. Chronic Medications for Maintenance of Lung Health (April, 2013)

These guidelines were developed by consensus based on expert opinion and a medical literature review to provide evidence-based recommendations for chronic medication use for lung health maintenance."

Clinical Indicators:

1. CM will review treatment plan and any changes and facilitate communication between member/family/caregiver and the other CF team members.
2. All CF members will be followed by a nutritionist that is familiar with the member’s medications and plan of care.
3. Member/family/caregiver will be educated on the importance of following their treatment plan for their prescribed medications.
4. Member will be provided educational resources through Health Wise and other appropriate resources as needed.

Links:

• Cystic Fibrosis Foundation
• Chronic Medications to Maintain Lung Health Clinical Care Guidelines

Reference: American Diabetes Association’s (ADA) “Standards of Medical Care in Diabetes-2019” for its Diabetes Guideline, Supplement 1 (January 2019).

Clinical Indicators:

1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c testing. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
2. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c Control <8.0%. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
3. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c poor control >9.0%. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
4. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had a retinal eye exam. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
5. The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had a nephropathy screening test or evidence of nephropathy. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
6. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) whose blood pressure was <140/90mm Hg. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
7. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one statin medication of any intensity during the measurement year.
(Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPD)
8. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80% of the treatment period. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPD)

Links:

• ADA Standards of Care

Reference: Treatment of Patients with Major Depressive Disorder, Third Edition

Institute for Clinical Systems Improvement Health Care Guideline titled, “Major Depression in Adults in Primary Care” (Seventeenth Edition, March 2016)

Clinical Indicators:

1. The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.

• Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, AMM)

Links:

• Institute for Clinical Systems Improvement Health Care Guideline Adult Depression in Primary Care (Updated March 2016)
• US Department of Health and Human Services/Agency for Healthcare Research and Quality (AHRQ) – “Adult Depression in Primary Care”

Reference: “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents - A Working Group of the Office of AIDS Research Advisory Council (OARAC). This guideline describes the best clinical practices based on available knowledge and a consensus of experts as of July 14, 2016. Health Resources and Services Administration (HRSA), Measure HVL-AD: HIV Viral Load Suppression, as presented in the Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid 2017 Technical Specifications and Resource Manual

Clinical Indicators:

1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (Health Resources and Services Administration)
3. Percentage of Enrollees with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links

• https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
• http://aidsinfo.nih.gov/guidelines
• https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-adult-core-set.pdf
• https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

Reference: “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults:Report From the Panel Members Appointed to the Eighth Joint National Committee” (JNC 8).

Clinical Indicators:

Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (BP was <140/90 mm Hg) during the measurement year.

• Results can be broken out by race and ethnicity.

 

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, CBP)

Links:

• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

Reference: CDC – Overweight and Obesity
AACE/ACE – American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Comprehensive Medical Care of Patients with Obesity, 2016

Clinical Indicators:

1. Adult BMI

The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
(Source: HEDIS® 2019, Vol. 2, Technical Specifications - ABA)

Links:

• https://www.cdc.gov/obesity/
• https://journals.aace.com/doi/pdf/10.4158/EP161365.GL

Reference: “Clinical Practice Guidelines for Quality Palliative Care,” 2018, 4th Edition, based on the National Consensus Project for Quality Palliative Care.

Clinical Indicators:

1. Care of the Older Adult-Advanced Care Planning
2. Discussion about preferences for resuscitation, life-sustaining treatment and end of life care. Evidence of advanced care planning must include one of the following:

• The presence of an advance care plan in the medical record.
• Care of the Older Adult-Pain Assessment 

At least one pain assessment during the measurement year, as documented through either administrative data or medical record review.
3.   Care for Older Adults-Medication review

• At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record, as documented through either administrative data or medical record review.

4.   Care for Older Adults-Functional Status Assessment

• At least one functional status assessment during the measurement year, as documented through either administrative data or medical record review.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications COA)

Links:

• Clinical Practice Guidelines for Quality Palliative Care

Reference: Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 (CDC)

Clinical Indicators:

The rate per 1,000 members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year at a high dosage (average milligram morphine dose [MME] >120mg).

The rate per 1,000 members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year who received opioids from multiple providers. Three rates are reported.

1. Multiple prescribers defined as the proportion of members receiving prescriptions for opioids for four or more different prescribers during the measurement year
2. Multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
3. Multiple prescribers and multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from 4 or more different prescribers and 4 or more different pharmacies during the measurement year.

Links:

• CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN
• Opioid Overdose
• Checklist for prescribing opioids for chronic pain
• https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

Reference:

APA Steering Committee on Practice Guidelines Practice Parameters for the Assessment and Treatment of Children and Adolescents with Schizophrenia. Second Edition, (2004).

Journal of the American Academy of Child & Adolescent Psychiatry (JAACAP) “Practice Parameters for the Assessment and Treatment of Children and Adolescents with Schizophrenia”, Volume 52, Number 9 September 2013

JAACAP

Clinical Indicators:

1. Metabolic Monitoring for Children and   Adolescents on Antipsychotics plus Medicare indicators for Schizophrenia as indicated (Source: HEDIS® 2019, Volume 2 Technical Specifications, APM)
2. Use of Multiple Concurrent  Antipsychotic in Children and Adolescents (Source: HEDIS® 2019, Volume 2 Technical Specifications, APC)

Links:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Schizophrenia

Reference: “The Management of Sickle Cell Disease”, The National Institutes of Health, National Heart, Lung, and Blood Institute NIH Publication No. 02-2117 June 2002 (Fourth Edition).
The New England Journal of Medicine, “The Management of Sickle Cell Disease”, NEJM 1999; 340:1021-1030 April 1999.

In some cases, RCTs cannot be done satisfactorily (e.g., for ethical reasons, an insufficient number of patients, or a lack of objective measures for sickle cell “crises”). Thus the bulk of clinical experience in SCD still remains in the moderately strong and weaker categories of evidence.

Not everyone has an efficacious outcome in a clinical trial, and frequency of adverse events, such as with long-term transfusion programs or hematopoietic transplants, might not be considered. Thus, an assessment benefit-to-risk ratio should enter into translation of evidence levels into practice recommendations. A final issue is that there may be two alternative approaches that are competitive (e.g., transfusions and hydroxyurea). In this case the pros and cons of each course of treatment should be discussed with the patients.

Clinical Indicators:

1. Percentage of members compliant with the flu vaccine in the current year
2. Percentage of members who received the meningococcal vaccination (quadrivalent meningococcal conjugate vaccine) starting age 2-10 years then every 5 years after)

Links:

• “The Management of Sickle Cell Disease”, The National Institutes of Health, National heart, Lung, and Blood Institute NIH Publication No. 02-2117 June 2002 (Fourth Edition)
• The New England Journal of Medicine, “The Management of Sickle Cell Disease”, NEJM 1999; 340:1021-1030 April 1999.
• Quality-of-care indicators for children with sickle cell disease.

Reference: American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Use Disorders,” Second Edition, (2006).
National Institute on Drug Abuse (NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
Dartmouth-Hitchcock Knowledge Map, Unhealthy Alcohol and Drug Use – Adult Primary Care – February 2017

Clinical Indicators:

1. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment
   
   • Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.(Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)
   • Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)
2. The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. 
   
   Two rates are reported:
   Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence
   
   • The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
   • Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, FUA)

Links:

• http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf
• https://www.drugabuse.gov/node/pdf/675/principles-of-drug-addiction-treatment-a-research-based-guide-third-edition
• https://med.dartmouth-hitchcock.org/documents/unhealthy-alcohol-drug-use-clinical-practice-guideline.pdf

Reference:Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2019.
The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP.

Clinical Indicators:

1.   The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, BCS)
2.   The percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21-64 years of age who had a cervical cytology performed every 3 years
• Women 30-64 years of age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

(Source: HEDIS® 2019, Vol. 2, Technical Specifications - CCS)

3.   The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Report two age stratifications:

• 16-20 years
• 21-24 years

The total rate is reported.
(Source: HEDIS® 2019, Vol. 2, Technical Specifications - CHL)

4.   The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, ABA)

Links:

• Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2019

U.S. Preventive Services Task Force:
• Breast Cancer Screening
• Cervical Cancer Screening
• Chlamydia ad Gonorrhea Screening

Reference: PA Department of Human Services Periodicity Schedule, and 2017 CDC Immunization Schedule Birth-18 Years and Catch-up

Clinical Indicators:

1. The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life:
   
   • No well-child visits.
   • One well-child visit.
   • Two well-child visits.
   • Three well-child visits.
   • Four well-child visits.
   • Five well-child visits.
   • Six or more well-child visits.
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications, W15)
   
2. The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, AWC)
3. The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); (Combo 3) (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CIS)
4. The percentage of members 3–6 years of age who had one or more well-child visits with a PCP during the measurement year. (Source: HEDIS® 2019, Vol. 2, Technical Specifications W34)

Links:

• Updates to PA EPSDT Program Periodicity Schedule (1/3/2018)
  
• CDC Well-Visit Schedule
  
• CDC Childhood Immunization Schedule for 2019 (0-6 yrs)(7-18 yrs)

Reference:American College of Obstetricians and Gynecologists (ACOG) Clinical Guidance and Publications

National Heart, Lung, and Blood Institute, National Institute of Health; Management Asthma During Pregnancy, Recommendations for Pharmacologic Treatment (2004) – NHLBI/NIH

ACOG – High Blood Pressure (Hypertension) - ACOG

American College of Allergy, Asthma & Immunology: Pregnancy and Asthma (2014) - ACAAI

Clinical Indicators:

1. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
2. Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery, as documented through either administrative data or medical record review.
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PPC)

Links:

• https://www.acog.org/Clinical-Guidance-and-Publications/Search-Clinical-Guidance
• https://www.nhlbi.nih.gov/files/docs/astpreg_qr.pdf
• https://www.acog.org/womens-health/high-blood-pressure-hypertension
• https://acaai.org/asthma/who-has-asthma-and-why/pregnancy-and-asthma

Reference:  Gateway adopts The American Academy of Pediatric Dentistry: Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents, 2013 and follows the PA Department of Human Services: MA Bulletin #99-17-10, Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule, August 7 2017.

The American Academy of Pediatric Dentistry (AAPD) intends for this guideline to help practitioners make clinical decisions concerning preventive oral health interventions, including anticipatory guidance and preventive counseling, for infants, children and adolescents. Since each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. Please note, these recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. In addition, the American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and continuity of care based on the individualized needs of the child. It is recommended that children receive their first dental exam by 12 months of age.

Please refer to the text of this guideline for supporting information and references. Refer to the text the Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance and Oral Treatment for Infants, Children, and Adolescents for supporting information and references.

The guideline is relative to Gateway’s child population (ages 0-21) which represents about 52% of the total Medicaid population. Dental caries is one of the most common chronic disease among children, yet it is can be reversible if detected in the early stages. If left untreated, decay will progress, and negatively impact quality of life.

Clinical Indicators:

1. The percentage of members 2–20 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the organization’s Medicaid contract. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Annual Dental Visit)
2. The percentage of dental exams within 12 months of age. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Dental Exams by 12 months of age)

Links:

• Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents
• MEDICAL ASSISTANCE BULLETIN
• American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health (pdf)