Q&A with the Health Care Safety Net Institute and Local Health Plans of California on collaborating to improve care
Earlier this year, the California Health Care Safety Net Institute (SNI) and the Local Health Plans of California (LHPC) gathered quality teams and executive leadership from 16 public health care systems and 12 local health plans across the state. This convening, the first of several in a series, aimed to build stronger partnerships between plans and systems, which share a mission to deliver high-quality and equitable care for individuals with Medi-Cal coverage.
In this interview, Giovanna Giuliani, Executive Director of SNI, and Linnea Koopmans, CEO of LHPC, discuss what plans and systems learned about each other at the convening, what forces are shaping these relationships today, and how a model collaborative approach resulted in significant gains for patients.
Q. Local health plans and public health care systems have worked together for many years. Why is strengthening these relationships a priority now?
Linnea Koopmans: As of January 2024, 99% of all Medi-Cal beneficiaries were in managed care, and over 70% of those statewide were enrolled in a local health plan.
And while our roots and history together go way back to the origins of the local plans, the stakes are higher both because the populations we’re serving are becoming more similar and more members are in managed care. This gives plans and systems the opportunity to align incentives and align programs. It feels like the right time to see what else we can do together to strengthen these partnerships and relationships locally.
Giovanna Giuliani: Because there are many more individuals in Medicaid managed care, and because of some of the state’s strategic initiatives, the state is really centering the plans as key partners in being able to accomplish Cal-AIM [California Advancing and Innovating Medi-Cal] and the state’s priorities. And the state is being much more thoughtful about the alignment of incentives, which I think is a good change.
Increasingly, the plans and the public health care systems, or any providers, are tied together financially. So, our actions when we collaborate will lead to shared success, and when we don’t collaborate will lead to shared loss.
Q. How is a lack of close collaboration between plans and systems ultimately detrimental to care?
Linnea: My initial thought is that if we’re saying a lack of collaboration is detrimental to patient care, I think we’re making the direct linkage between partnerships and collaboration influencing health outcomes and quality of care. And I think that’s the premise of all this.
The success of local plans and public health care systems is highly interdependent. As we quite literally serve the same members or patients, when we work together instead of in silos, we will see greater improvement in timely access to care and quality of care.
Giovanna: I think you might see a lack of collaboration in the way a patient experiences care. For example, if you go into a hospital, then you need to follow up with your primary care provider. That might not be a public health care system. That might be another type of provider that the plan manages. Then you might need to go to step-down care. You might need follow-up care and county behavioral health. There are all of these sort of handoffs that public health care systems may not have a view into, but plans do. So, we really need to be coordinated in ensuring those transitions and handoffs take place.
Q. What examples or evidence do you have that closer collaboration ends up benefiting patients?
Linnea: The proof is in the pudding with the outcomes that IEHP [Inland Empire Health Plan] and Riverside University Health System presented at the convening.* That was the most compelling part.
They talked about the starting point for leadership commitment as the shared vision partnership. They talked about meeting regularly. They talked about data sharing. And at the end of the day, they showed the difference it made on their quality scores, which directly translated to more people having controlled blood pressure. And it wasn’t just a small difference. It was a really meaningful difference.
*The IEHP-RUHS collaborative approach resulted in increasing patients’ blood pressure control 15% between 2021 and 2023.
Giovanna: In that Riverside example, the plan did a lot of work around data sharing, but it also supported the remote patient monitoring for blood pressure, sending patients the blood pressure cuffs. And that was obviously a critical component of success to that work, as well as how they supported one another as organizations and as people. There’s a lot I love about that Riverside continuum because it lays out what’s possible.
Q. At your first plan-system convening earlier this year in Burbank, did anything stand out to you or surprise you? Any observations?
Linnea: The energy and interest around collaboration was palpable. The attendance by nearly all local plans and public health care systems signified an appetite to learn from one another about how they are leveraging partnerships to improve quality outcomes. The room was packed!
Plans and their system partners have success stories to share, and the information about how they do this work together is not proprietary. There’s an interest in sharing – in detail – how plans and systems have solved problems, improved quality metrics, and unified their leadership.
Giovanna: I have a couple of ahas from our first convening. One was that I learned a lot from Linnea about what financial incentives are at stake for the plans, which I didn’t know at my level. And similarly, I think there were sort of raised eyebrows, in particular, about how big the Quality Incentive Pool [QIP] is. It’s $1.8 billion.
I shared at the convening what QIP means to our systems. The loss of any of those dollars really impacts care on the ground, direct services to patients. And when I talked to a couple of plans, they shared that maybe a few people at their plan knew about QIP, but it didn’t penetrate very far. And they certainly did not know about the level of financial incentive. So, I think we at SNI need to do a better job of figuring out how we can communicate about QIP, and we need to encourage our members to do a better job of communicating about what’s at stake.
I joined one table where folks from a plan and system were talking, and they realized that they had some similar touch points around QIP, CalAIM, and transitions of care, but none of it was coordinated. So, they had been working together, but in a fragmented, siloed way. There wasn’t an overall governance structure. When they left, their intention was to get everyone together to build out this structure so they can work together more systematically, and all be on the same page.
The other big aha for me was that some of the people really were in the room for the first time. Some flew from Northern California to Southern California to be at this meeting, but they’re not meeting in their local region on a regular basis. We need to create an environment and a communication approach where those relationships are developed with more intentionality on an ongoing basis.
Q. Linnea, what challenges do the plans face that systems might not be aware of or appreciate?
Linnea: There is an interdependence between plans and systems that may not always be apparent. It’s not a matter of systems doing what they need to do to earn QIP dollars and plans doing what they need to do to avoid sanctions. Given the magnitude of how many patients overlap in who the systems and plans serve, the interests are aligned.
Over the last few years since COVID, with CalAIM and the state’s Comprehensive Quality Strategy, and the recent implementation of the 2024 MCP [Medi-Cal managed care plan] contract, the expectations around how the Medi-Cal system performs have really changed.
This means that for the plans, there are now multiple different policies and programs that are driven by quality performance. While there is generally alignment across those programs with respect to the priority measures or populations, the stakes for performance are now much higher.
So, for example, plans are subject to sanctions and penalties if they do not meet the established minimum performance levels, and MCP enrollment is now driven based on quality as the auto-assignment algorithm now only considers a plan’s quality performance. All of these policies and programs directly impact how the plans are engaging with and supporting their public health care system partners in quality improvement efforts.
Q. What are you collectively focusing on next?
Giovanna: I think it’s building out what Linnea has talked about, which is we have to make sure the momentum continues between the plans and the systems. Whether or not that’s something that we host or facilitate or encourage, we need to figure out how to keep that momentum for those who have already started the work, and frankly, how to help kickstart it for other pairs.
Our other intention over the next couple of months is to dive more deeply into the content for our October plan-system convening. It will be around the exchange of data between the plans and systems so that they have similar information and a shared understanding of performance that matches. That can really be a barrier to forward progress, so we really need to try and figure out how to tackle it together.
For more information about promising practices and pilots of system-plan collaboration, the specific external drivers that impact systems and plans, and overlapping quality measures, please see our reference guide.
For greater context about SNI and LHPC Institute’s partnership, and why collaboration is essential to improving quality, please see our “Partnering to Improve Quality of Care” issue brief.
GPP PY9 Health Equity Reporting Manual User Agreement AMA PQA CMS v20231211
End User Agreement
Please review this agreement and click “Accept” at the end of this agreement if you agree to the terms of this agreement. If you do not agree, please click “Cancel”; in this case, you will not be able to access the Reporting Manual.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA). All Rights Reserved. CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the QIP PY7 Reporting Manual solely for your own personal use and only for participating in state governmental healthcare related programs supported by and/or administered by California Health Care Safety Net Institute (SNI). You acknowledge that the “AMA” holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave, Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site (http://www.ama-assn.org/go/cpt.).
U.S. GOVERNMENT RIGHTS
This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the AMA, 330 Wabash Avenue, Chicago, IL 60611. The AMA does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The AMA reserves all rights to approve any license with any Federal agency.
DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with SNI, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.
CMS MEDICAID ADULT AND CHILD CORE SET
License Agreements
Please review the licensing information below and indicate your agreement and acceptance.
LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT)
End User Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60654. Applications are available at the AMA website, http://www.ama-assn.org/go/cpt.
Applicable FARS\DFARS Restrictions Apply to Government Use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the AMA, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL, 60611- 5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Defense Department procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non- Department of Defense Federal procurements.
AMA DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
CMS DISCLAIMER
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)
These materials contain the NUBC Official UB-04 Specifications Manual and data codes (UB-04 Data), which are copyrighted 2022 by the American Hospital Association (AHA), Chicago, IL. Reproduced with permission. No portion of the AHA copyrighted materials may be copied without express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.
Making copies or utilizing the content of the UB-04 Manual, including codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of the UB-04 Manual or any portion thereof, including the codes and/or descriptions is only authorized with an express license from the AHA.
The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in the agreement. By clicking below on the button labeled “Accept” you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.
If you do not agree with all terms and conditions set forth herein, click below on the button labeled “Do Not Accept” and exit from this computer screen.
If you are acting on behalf on an organization, you represent that you are authorized to act on behalf of such an organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.
1. Subject to the terms and conditions contained in this agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. Applications are available at the NUBC website, http://www.nubc.org/.
3. The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER
The AHA hasn’t reviewed and isn’t responsible for the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessary represent the views of the AHA. CMS and its products and services aren’t endorsed by the AHA or any of its affiliates.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES
UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice to you if you violate the terms of this agreement. The AHA is a third-party beneficiary to this agreement.
CMS DISCLAIMER
The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I agree”.
QIP PY7 Reporting Manual User Agreement AMA PQA CMS v20231211
End User Agreement
Please review this agreement and click “Accept” at the end of this agreement if you agree to the terms of this agreement. If you do not agree, please click “Cancel”; in this case, you will not be able to access the Reporting Manual.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA). All Rights Reserved. CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the QIP PY7 Reporting Manual solely for your own personal use and only for participating in state governmental healthcare related programs supported by and/or administered by California Health Care Safety Net Institute (SNI). You acknowledge that the “AMA” holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave, Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site (http://www.ama-assn.org/go/cpt.).
U.S. GOVERNMENT RIGHTS
This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the AMA, 330 Wabash Avenue, Chicago, IL 60611. The AMA does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The AMA reserves all rights to approve any license with any Federal agency.
DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with SNI, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.
PHARMACY QUALITY ALLIANCE COPYRIGHT STATEMENT
By agreeing to this policy, user accepts the following limitations of the QIP’s use of the Pharmacy Quality Alliance (PQA) Opioid measures and code sets: To accurately calculate the measure rates, the PQA value sets are required. User acknowledges that the PQA measures and value sets will only be used for the sole purpose of evaluating and improving opioid use for populations served by Public Health Care Systems (PHS) and District and Municipal Hospitals (DMPH) and will not be used for other purposes. Except for the purpose indicated above, the PQA measures and value sets will not be used for any other commercial product, service or value-added benefit. User also acknowledges that the information and PQA value sets will not be forwarded or provided to anyone outside of SNI, the California Department of Health Care Services (DHCS), the PHS or the DMPH.
CMS MEDICAID ADULT AND CHILD CORE SET
License Agreements
Please review the licensing information below and indicate your agreement and acceptance.
LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT)
End User Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60654. Applications are available at the AMA website, http://www.ama-assn.org/go/cpt.
Applicable FARS\DFARS Restrictions Apply to Government Use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the AMA, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL, 60611- 5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Defense Department procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non- Department of Defense Federal procurements.
AMA DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
CMS DISCLAIMER
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)
These materials contain the NUBC Official UB-04 Specifications Manual and data codes (UB-04 Data), which are copyrighted 2022 by the American Hospital Association (AHA), Chicago, IL. Reproduced with permission. No portion of the AHA copyrighted materials may be copied without express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.
Making copies or utilizing the content of the UB-04 Manual, including codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of the UB-04 Manual or any portion thereof, including the codes and/or descriptions is only authorized with an express license from the AHA.
The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in the agreement. By clicking below on the button labeled “Accept” you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.
If you do not agree with all terms and conditions set forth herein, click below on the button labeled “Do Not Accept” and exit from this computer screen.
If you are acting on behalf on an organization, you represent that you are authorized to act on behalf of such an organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.
1. Subject to the terms and conditions contained in this agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. Applications are available at the NUBC website, http://www.nubc.org/.
3. The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER
The AHA hasn’t reviewed and isn’t responsible for the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessary represent the views of the AHA. CMS and its products and services aren’t endorsed by the AHA or any of its affiliates.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES
UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice to you if you violate the terms of this agreement. The AHA is a third-party beneficiary to this agreement.
CMS DISCLAIMER
The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I agree”.
