Condition Optimization Program (COP)

Condition Optimization Program (COP) Provider User Guide (PDF)

Under its contract with the Pennsylvania Department of Human Services (DHS), Keystone First is responsible for collecting and submitting complete and accurate encounter data for all services furnished to its members. One of the key components to ensuring that our encounter data is complete and accurate is validation of the diagnoses reflected in the encounters that we submit to DHS.

DHS uses the encounter data from its managed care plans in a number of ways, including to more accurately gauge the disease acuity within our member population, which helps to predict expenditures for delivery of care. For managed care plans such as Keystone First, member-level data obtained through encounters allows DHS to gain a more in-depth understanding of the factors driving cost and quality within the Medicaid program.

Keystone First has developed the Condition Optimization Program (COP) to compensate providers for completing the essential, administrative activities that help to validate encounter data and for encouraging our members to routinely visit their primary care provider (PCP).