Alignment of beneficiaries Clause Samples

Alignment of beneficiaries. ‌ Next Generation Beneficiaries are identified prospectively, prior to the start of the Performance Year, on the basis of each Beneficiary’s receipt of QEM services in the 2-year alignment period ending prior to the Start Date. Similarly, Beneficiaries who are aligned in the base year for purposes of calculating the base year expenditure are identified on the basis of each Beneficiary’s receipt of QEM services in the 2-year alignment period ending prior to the start of the base year. Alignment of a Beneficiary is determined by comparing, for the applicable 2-year alignment period: 1. The weighted allowable charge for all QEM services that the Beneficiary received from the ACO’s Next Generation Professionals; 2. The weighted allowable charge for all QEM services that the Beneficiary received from each provider or supplier not participating in a Next Generation ACO Model- participating accountable care organization. A Beneficiary is aligned for purposes of the Next Generation ACO Model based on the Next Generation Professionals from which the Beneficiary received the largest amount of QEM services during the 2-year alignment period. A Beneficiary will generally be aligned to the ACO if he or she received the plurality of QEM services during the 2-year alignment period from the ACO’s Next Generation Professionals. Only claims that are identified as being furnished by the primary care specialists listed in Table 5.3 of this Appendix B and the non-primary care specialists listed in Table 5.4 of this Appendix B will be used in Beneficiary alignment determinations.