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Health Care Quality Assessment Form Provider Incentive

Santa Clara Family Health Plan (SCFHP) is encouraging primary care providers (PCP) to assess their DualConnect member’s medical conditions during their patient’s Medicare annual wellness visit.

PCPs who perform an annual wellness visit and complete the Health Care Quality Assessment Form (HCQAF) are eligible to receive $100.00 payment, per DualConnect member.

To request your organization or doctor office’s HCQAF contact the SCFHP Risk Adjustment team at

Annual wellness visit frequently asked questions

What is a Medicare annual wellness visit?

During a Medicare annual wellness visit providers will develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA). An annual wellness visit also includes: medical and family history, list of current providers, biometrics, cognitive function, potential risk factors for depression, functional ability and level of safety, written screening schedule for the next 5-10 years, list of risk factors and conditions for interventions, health advice and referrals, and voluntary advance planning.

The Medicare annual wellness visit is a covered benefit once every 12-months. Medicare does not cover routine physicals. For information on Medicare wellness visits see

Who can bill for a Medicare annual wellness visit?

Medicare Part B covers annual wellness visits if performed by a:

  • Physician (MD or OD)
  • Qualified Non-Physician Practitioner (PA, NP, CCNS)

Medical professional directly supervised by a physician

How do I bill for an annual wellness visit?

Use these HCPCS codes to file annual wellness visit claims:

  • G0438 initial visit
  • G0439 subsequent visit
  • If an E/M service is needed, e.g., 99213, amend modifier -25 to the CPT code

You can only bill G0438 or G0439 once in a 12-month period. HCPCS codes G0438 or G0439 must not be billed within 12-months of a Medicare initial preventive physical examination (IPPE, G0402). To learn more about Medicare IPPE visit:

What is a Health Risk Assessment?

A Health Risk Assessment (HRA) is a questionnaire that involves collecting health-related information from Medicare members. Providers use this information to evaluate the health status or health risk of their patient. The HRA is also a required component of the annual wellness visit. If your practice does not have a compliant HRA form, you can download SCFHP's HRA form.

Visit to see if your practice’s form is CMS compliant.

Note: to save time SCFHP recommends mailing the HRA to the patient so it can be completed before the visit. However, the HRA can be completed during the visit.

Documentation and Coding Best Practices

Medical record documentation is used to determine support for medical necessity, and for diagnoses that were submitted on claims. Therefore, documentation should be an accurate description of your patient’s health status, including: diagnosis, co-morbidities, severity, progression, and treatment. See the documentation and coding newsletters at for coding tips as outlined by ICD-10-CM Official Guidelines for Coding and Reporting and the Centers for Medicare and Medicaid Services.

HCQAF frequently asked questions

What is the purpose of the HCQAF activity?

The HCQAF encourages providers to schedule an annual wellness visit and document vital information from the patient. The HCQAF activity requires a health risk assessment questionnaire, assessment of all active medical conditions, and a personalized care plan. The Centers for Medicare & Medicaid Services (CMS) expects providers to assess their patient’s active, ongoing and chronic conditions at least once per calendar year. This includes comorbidities and conditions that frequently do not get reported on claims e.g., transplant status, amputations, old MIs, and artificial openings.

How do I fill out the Diagnosis Code History section of the assessment form?

Assess each diagnosis and mark the current status as either active, resolved or non-applicable (N/A). Document all active diagnoses in the clinic note to the highest severity level. The Diagnosis Code History might not have pre-populated diagnosis codes or descriptions. There are multiple reasons why there may be no pre-populated data. For example, no chronic conditions have been submitted on a claim before, or this may be the patient’s first visit. Treat these forms as you would if they contained diagnosis codes or descriptions. Schedule an annual wellness visit with these patients and complete the remaining requirements to qualify for the additional payment.

How do I fill out the Gaps in Care section of the assessment form?

If any of the HEDIS measures listed in the Gaps in Care section apply to your patient, mark the activities that have been performed, reviewed, referred and or ordered

Can I get the $100 incentive if I complete an audio only visit as the annual wellness visit?

To be eligible for the $100.00 additional payment visits must be performed either face-to-face or via two-way interactive audio and video.

How do I know I completed the HCQAF correctly?

Before faxing the assessment form, use the HCQAF Checklist that was included with your form. The checklist will help determine if the assessment form is complete and will be eligible for additional payment.

Where do I send the completed assessment forms?

Fax the completed assessment form, Health risk assessment and clinic note for each patient to

Attn: Risk Adjustment

Fax: 1-408-874-1439

Who do I contact if I have questions?

For questions or concerns contact Risk Adjustment at

When and how will I receive my incentive payment?

A $100.00 payment will be offered for completed assessment forms and medical record documentation per DualConnect member.

Once the submitted documentation has been confirmed as complete and meets CMS standards, SCFHP will make quarterly payments to the Tax Identification Number associated with the rendering/submitting physician. This payment will be made separately and not part of the claims remittance.