Process to Remove Approved Exemptions for Clinical Consideration from the Optum Denominator
Health plans have requested to have a process to remove members from their denominators when a preventive service (TCD, antibiotics or hydroxyurea) may not be appropriate for the member due to a special clinical reason. The process for requesting the removal of a member from a measure denominator is outlined below. Requests may be made in conjunction with the narrative report sent annually to MDHHS. Requests must be submitted to MDHHS by September 30, 2025, for exemptions to be included for the reporting period.
1. Health plans planning to submit a “Request for Exemption for Clinical Consideration” for any member(s) should first verify in CC360, as per MDHHS guidance, whether the members for whom exemptions are requested are currently included in the CC360 denominator.
2. If members ARE included in CC360 denominator, health plans complete the “Request for Exemption for Clinical Consideration” table in narrative report for these members.
3. If members ARE NOT included in CC360 denominator, health plans do not request exemption for these members, as this is not necessary.
4. Health plans submits their narrative report template with the “Request for Exemption for Clinical Consideration” to MDHHS by September 30, 2025.
5. MDHHS sends “Request for Exemption for Clinical Consideration” information to the UM team for review.
6. The UM team provides feedback to MDHHS regarding validity of requests for exemptions.
7. MDHHS verifies feedback and requests that Optum remove approved members from health-plan denominators.
8. Optum removes approved members from the denominator for the annual performance bonus (07/01/24 – 06/30/25 measurement year). These members will also be removed from the three subsequent quarterly data pulls. This process will be repeated annually.
Please note, members who are excluded from the quality measures will still be visible in CC360 member level detail to support data reconciliation. The CC360 extract detail will indicate that they have been excluded from the quality measure rate.
9. MDHHS delivers final template scoring to health plans.