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Health Endeavors' Primary Care First (PCF) Program:

Network Manager:  Patient Rosters and Hierarchy

Network Manager

Network Manager provides a platform for clients to determine how they want to view their quality and financial performance metrics.  Patient rosters were delivered to the 4i data hub in January 2021.

Financial Network Performance:  Analytics Dashboard

PCF Financial Peformance
  • We generate Analytics Dashboards using Medicare CCLF claims data (monthly 4i data hub feed referenced above) (estimated timeline to populate analytics once data is received is 1 week).   

    • –Features (View Video Series)

      • Analytics Dashboard:  Risk stratification and benchmarking using hierarchy defined by client.

        • Drill down to Provider Quality and Financial Performance Scorecard​

      • Aggregate Expenditure and Utilization Interactive Tool

      • Query Builder

        • Define your own reports using a query builder tool​

      • Visual Drill Downs

        • HCC Recapture Rate, Lost Revenue, Benchmark​

      • Quick Reports

        • Admissions, Readmissions, Emergency Room utilization and more

        • Out-of-Network Migration

        • Acute Hospital Utilization (AHU) Quality Measure

Quality Network Performance:  Performance Scoring, Gap Analysis, Provider Scorecard

  • Track eCQM quality measure performance for Diabetes Hemoglobin A1c (HbA1c) Poor Control (>9%)​, Controlling High Blood Pressure and Colorectal Cancer Screening

    • –Why?

      • eCQM measures must be submitted using a QRDA III file from the EHR.  If you have more than one EHR we will combine the QRDA III files into one JSON file.  However, you will want to track year-round performance using CPT II codes, QRDA I, manual key, and SMART on FHIR to avoid poor performance surprises at end of year.  The QRDA III file will need to include all patients that met the denominator from all payers.  

  • Collect Advance Care Plan (CQM) measure in central qualified registry repository

    • Why?

      • Your PCF organization will be expected to report Advance Care Plan quality measure for 70% of your patients from all payers via a qualified registry or other IT vendor from January – March for the prior year.

      • Data imports used for PCF patients are CPT II codes collected from Medicare CCLF claims data and SMART on FHIR​ get calls from your EHR. The requirement is did you have a discussion with the patient and notation in the medical record.

  • To participate in SMART on FHIR your EHR must be connected to our Patient Lookup solution.  Use ConnectMyEHR project plans for implementation. 


  • Submit patient rosters and claims data for Advance Care Plan non-PCF patients 

    • To achieve compliance with 70% of your patients you will need to provide Medicare and commercial patient rosters in a tab-delimited text file..  We require Medicare claims data but not commercial claims data.   SMART on FHIR and flat file data imports will be used to populate measure responses for non-PCF patients as well. 

  • As a qualified registry, Health Endeavors is required to audit and provide performance scoring on-demand to clients.   As a qualified registry we are required to work with Medicare on a data validation plan each year when we renew our registry and at the close of the year.  Our Medicare data validation plan requires us to conduct an annual audit of each clinic participating in the registry.  

    • This involves our team submitting a random sample of patients (securely) to the clinic to be audited by the client in the EHR to verify measure documentation.   After the audit of the EHR documentation, we then meet with the clinic to review the findings.

  • Our quality solution deliverables are gap analysis, completion rate and performance scoring for each measure in the qualified registry.

Quality Network Performance

Patient Lookup - Data Point of Care

Patient Lookup- DPC
  • Setup Medicare 4-year health history accessible in the EHR (point of care) or via

    • Why?

      • A 4-year health history refreshed every 7 days in the EHR or will assist your team with PCF success by using HCC Coding Assist, Risk Score, Benchmark, Cost and Utilization features during patient encounters (View Video Series).  This is also how SMART on FHIR calls are made to your EHR for the Advanced Care Plan (CQM) measure in Epic and Cerner (and soon AthenaHealth and Allscripts)

      • What we need to complete this task

        • Initiate request for Medicare 4-year claims history from Medicare Data Point of Care (DPC)

          • Review instructions ​here

        • Retrieve Medicare PCF patient roster and CCLF claims files for Part A, B, and D from 4i data hub and remit to Health Endeavors using SFTP.  Contact to setup SFTP account.  In the alternative, add Kristine Gates, 8955 E. Pinnacle Peak Rd, Suite 103, Scottsdale, Arizona 85255,, 480.912.1209 as a contact in your 4i portal to obtain access directly to the Medicare CCLF claims files

        • Setup ConnectMyEHR kickoff call (estimated timeline is 6 weeks to complete EHR integration) and review your EHR Project PlanRequest Here



Q.  Is it unusual that we have not received notice about access to the 4i data hub and CCLF files?

          A.  No, however we expect delivery of the Medicare CCLF claims files aby April 1, 2021.

Q.  Is PCF subject to the 70% of patients from all payers rule for quality measure reporting?

          A.  Our understanding is yes for both the eCQM and CQM Advanced Care Plan (ACP) measure. 

Q.  What is the name of the qualified registry?

          A.  Health Endeavors

Select Security Official

Who is your Security Official?     

Identify the person(s) that will be responsible for managing users in our My Team solution

Security Official Information 

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