The final 2022 PIP manual is available

Our final 2022 PCP Incentive Program (PIP) manual is now available on You can find the manual on the PCP Incentive Program webpage. (login required)

We’re also working to update information on our PIP webpages. You can expect the following PIP webpages to be finalized January 2022:

  • Care management
  • Social determinants of health (SDoH)
  • Behavioral health collaborative care (BHCC)
  • Medication therapy management (MTM)
  • Provider Roster Application (PRA)

Overview of 2022 program changes

New 2022 measures:

  • Care for Older Adults (COA)
  • Osteoporosis Management in Women Who had a Fracture (OMW)

Revised 2022 measures:

  • Eye Exams for Patients with Diabetes (EED) (name change only)
  • Kidney Health Evaluation for Patients with Diabetes (KED)
  • Care Management
  • Social Determinants of Health (SDoH)
  • Health Information Exchange Participating with MiHIN
  • Behavioral Health Collaborative Care (BHCC)
  • Medication Therapy Management (MTM)

Retired measures:

  • Diabetes Care Monitoring for Nephropathy
  • Optimal Diabetes Care
  • ED Visits: PCP Treatable
  • Acute Hospital Utilization (AHU)
  • Emergency Department Utilization (EDU)

Other Program Revisions/Information:

  • Attribution model
  • Provider Roster Application
  • Filemart reporting
  • Removal of non-HEDIS exceptions (Non-adherent member exclusions, Special Exceptions, etc.)
  • Adoption of Clinical+ starting March 2022
  • Retirement of Report 70 (supplemental data RPX report)

Measure changes include:

Program measure grid (pg.5)

The product payout and targets are included in the final manual. The grid provides an overview of PIP including the measure titles, product targets and payouts. Targets were retained based on pre-COVID-19 performance.

Attribution model (pg. 6)

We’ve updated the PIP attribution model to align with industry standards. Our model is primarily based on utilization to ensure that members enrolled in all health plans may be included in PIP.

Glossary and administrative details (pg. 9-15)

We’ve updated many components of our glossary and administrative details to better communicate the program. Please take time to review these updates and familiarize yourself with the details of PIP.

Clinical+ (pg. 9)

Clinical+ is a new tool replacing Patient Profile. It assists in closing quality gaps in care.

Provider Roster Application (PRA) Tool (pg.14)

We require ACNs to attest to their PCP roster in the PRA tool to be eligible for PIP.

Care for Older Adult (COA) (pg. 27)

This is a new incentivized measure for PIP in 2022. Care for Older Adults is a Medicare 5 Star quality rating measure for DSNP members 66 years and older who had each of the following during the measurement year:

  • Medication review
  • Functional status assessment
  • Pain assessment

Osteoporosis Management in Women who had a fracture (OMW) (pg. 35)

This incentivized measure applies to female Medicare members 67–85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture.

Eye Exams for Patients with Diabetes (EED) (pg. 44)

We’re aligning with HEDIS technical speculations and changing the name of “Diabetes Care: Annual Retinal Eye Exam” to “Eye Exams for Patients with Diabetes (EED)”

Kidney Health Evaluation for Patients with Diabetes (KED) (pg.47)

We’re aligning with HEDIS and have retired the Diabetes Care: Monitoring for Nephropathy measure. We are replacing this measure with the Kidney Health Evaluation for Patients with Diabetes (KED).

Payout is available for Medicare members. All other members will be report only during 2022 PIP.

Care Management (pg. 64)

The following components are required to meet the incentive:

  • Component 1: Active PCMH recognition
  • Component 2: Quality Health Professional (QHP) licensure, training, and continuing education
  • Component 3 (revised): Claims submission (2% target applied to all practice groups)
  • Component 4 (new): Meet or exceed three quality measures by product/population 

For additional details on this measure please refer to the PIP manual and/or the Care management web landing page. (login required)

Social Determinates of Health (SDoH) (pg. 70)

The following components are required to meet the incentive:

  • Component 1: Active PCMH recognition
  • Component 2: Billing z-codes (new z-codes added)

The attestation component of this measure has been removed. Additionally, the code set for the denominator calculation has been changed to align with the new PIP attribution model.

Health Information Exchange Participation with MiHIN (pg. 72)

ACNs contracted with MiHIN and participating in at least five out of seven identified use cases are eligible for a per member per month (PMPM) incentive across all products. Additional details include:

  • Added SDoH as an optional use case
  • Attestation is not required
  • Participation status will be provided by MiHIN

Behavioral Health Collaborative Care (BHCC) (pg. 75)

The following components are required to meet the incentive:

  • Component 1: Active PCMH recognition
  • Component 2 (new): Implement a systematic case review (SCR) tool
  • Component 3 (new): Implement collaboration with a psychiatric consultant
  • Component 4: Submit an attestation of compliance
  • Component 5: Attend quarterly Priority Health sponsored meetings to discuss BHCC

Medication Therapy Management (MTM) (pg. 78)

The following components are required to meet the incentive:

  • Component 1: Submit completed MTM point of care attestation survey
  • Component 2: Submit pharmacist staffing updates for attested practice groups

Filemart report inventory changes (pg. 119)

To streamline reporting, we’re changing the inventory of Filemart reports in 2022. Please refer to the Filemart report inventory at the end of the 2022 PIP manual for more information.