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.
- This measure has the same structure as measures in the Effectiveness of Care domain. The organization must follow the Guidelines
for Effectiveness of Care Measures when calculating this measure.
- Only the Administrative Method of data collection may be used when reporting this measure for the commercial population.
- Refer to Appendix 3 for the definition of PCP and OB/GYN and other prenatal care practitioners.
- This measure is based on the CMS and American Academy of Pediatrics guidelines for EPSDT visits.
Refer to the American Academy of Pediatrics Guidelines for Health Supervision at www.aap.org and
Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (published by
the National Center for Education in Maternal and Child Health) at www.Brightfutures.org for more
information about well-care visits.
||Commercial, Medicaid (report each product line separately).
||12–21 years as of December 31 of the measurement year.
||The measurement year.
||Members who have had no more than one gap in enrollment of up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid member for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled).
||December 31 of the measurement year.
Denominator Exclusions (when applicable): Members in hospice are excluded from the eligible population.
If an organization reports this measure for the Medicaid product line using the Hybrid method, and a member
is found to be in hospice or using hospice services during medical record review, the member is removed
from the sample and replaced by a member from the oversample. Refer to General Guideline 20: Members in Hospice.
|At least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year, as documented through either administrative data or medical record review. The PCP does not have to be assigned to the member.|
|Refer to Administrative Specification to identify positive numerator hits from the administrative data.|
|Documentation in the medical record must include a note indicating a visit to a PCP or OB/GYN practitioner, the date when the well-care visit occurred and evidence of all of the following:|
Visits to school-based clinics with practitioners whom the organization would consider PCPs may be counted if documentation that a well-care exam occurred is available in the medical record or administrative system in the time frame specified by the measure. The PCP does not have to be assigned to the member.
The organization may count services that occur over multiple visits, as long as all services occur in the time frame specified by the measure.