Information Last Updated: 3/18/2022
Brand New Day values the care and support you provide to our Brand-New Day members and because of this, we are pleased to inform you that you are eligible to participate in our 2022 Quality Incentive Program that offers a $200.00 bonus for completing the attached Annual Physical Examination Form before July 1. 2022. Annual Exams with dates of service after July 1, 2022, will be reimbursed at $150.00. This form is different from what you currently use in your office as it contains unique patient health information data that you may find to be very helpful.
Completing the form is easy. The Annual Wellness Examination Form has three (3) parts
PATIENT FORM (pg. 1 & 2): Give this form to the patient to complete prior to the visit or as they wait in your lobby before they see you.
MEDICAL ASSISTANT FORM (pg. 3 & 4): This form is for your office staff to complete and answer
PROVIDER FORM (pg. 5 to the end): This form is for the treating provider to complete and answer.
MEDICAL HISTORY REPORTED TO THE HEALTH PLAN contains important healthcare data unique to each patient based on past claims data including primary care visits, specialist visits, hospitalizations, diagnosis/HCC and Rx claims. This are important information about your patient that can help identify and address chronic conditions that may otherwise go undiagnosed and/or untreated.
COMPLETE THE FOLLOWING is the section in which you complete during the patient’s Annual Physical Examination visit with you. It contains preventive care reminders and screenings that meets Healthcare Effectiveness Data and Information Set (HEDIS).
In order to receive reimbursement, you must:
Fully Complete the Annual Wellness Examination Form. (Annual Wellness Exam Form)
Send us a copy of your Electronic Medical Record (EMR) progress notes for the visit.
Completed W-9 form once a year (blank one attached). AWE submission without a copy of your W9 will delay processing. Required for every submission. (W-9 Form)
Please contact provider relations for any follow up, questions or concerns regarding the Quality Bonus at Provider_Services@universalcare.com Brand New Day Health Plan would like to thank you for participating in the Quality Incentive Program.
Every form submission must include an updated W9 even if you have previously provided one.
Drag and Drop your files here:
All Annual Wellness Exams require a W9.