Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Policy #:MA00.033g

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

The specific services that are listed in Attachments A and B are eligible to be paid above capitation to Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) primary care providers (PCP), this includes Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs) practicing in primary care:
  • Attachment A applies to Pennsylvania PCPs
  • Attachment B applies to New Jersey PCPs

PCPs are also eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

In order to ensure proper reimbursement for services, PCPs must submit the appropriate claim form.
Policy Guidelines

Laboratory testing by a primary care provider (PCP) must be performed at the PCP’s designated capitated outpatient laboratory, with the exception of the laboratory tests that are listed in Attachments A and B which can be performed at the PCP's office.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, services that are outlined in Attachments A and B are covered under the medical benefits of the Company’s Medicare Advantage products.

Description

A primary care provider (PCP) is a participating professional provider who is selected by a member and is responsible for providing all primary care services and for authorizing and coordinating all covered medical care, including referrals for specialist services.

Capitation is the payment that a professional provider or participating facility receives in advance of services for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) members who utilize their referred benefit. Capitation, as it applies to a PCP's practice, is based on the provider's panel of members each month and is paid as a set dollar amount.

Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) PCPs provide care that is medically necessary and preventive in nature. Generally, HMO and HMO-POS PCP practices are paid a monthly fee (capitation) for members who have selected them as their primary health care service professional provider. The majority of services that are provided by the PCP are included in this monthly capitation payment.

Payment above capitation refers to the fee-for-service reimbursement that a participating PCP may receive for rendering services to an HMO or HMO-POS member.

The services that are paid over and above the monthly capitation payments (above capitation) are listed in Attachments A and B.
References

Evidence of Coverage.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachments A and B.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachments A and B.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: PENNSYLVANIA: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Description: Pennsylvania Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

Attachment B: NEW JERSEY: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Description: New Jersey Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers







Policy History

MA00.033g:
08/19/2019This version of the policy will become effective 08/19/2019.

This policy was updated to remove language specific to Delaware products and corresponding attachment, Services Paid Above Capitation for Delaware Primary Care Providers (formerly Attachment A). AmeriHealth discontinued providing health coverage in the Delaware market on January 1, 2014.

Attachment A now represents Services Paid Above Capitation for Pennsylvania Primary Care Providers. Attachment B continues to represent Services Paid Above Capitation for New Jersey Primary Care Providers.

In addition, this policy was expanded to allow certain place of service and provider exceptions for influenza testing services.
  • The following CPT codes have been added to Attachments A and B: 87501, 87502, 87503, 87275, 87276, 87400.

MA00.033f:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT codes have been deleted from Att B of this policy:
11100, 11101

The following CPT codes have been added to Att B of this policy:
11102, 11103, 11104, 11105, 11106, 11107

REVISIONS FROM MA00.033e:
12/01/2017Physician Assistants (PAs) practicing within the scope of their license may be eligible to be paid above capitation to Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) primary care providers (PCPs) for services listed in Attachments A, B, and C.

REVISIONS FROM MA00.033d:
10/01/2017This policy has been identified for a CPT code update, effective 10/01/2017.
The following CPT code has been added to this policy: 92227

REVISIONS FROM MA00.033c:
08/01/2017Certified Registered Nurse Practitioners (CRNPs) practicing within the scope of their license may be eligible to be paid above capitation to Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) primary care providers (PCPs) for services listed in Attachments A, B, and C.

REVISIONS FROM MA00.033b:
03/18/2016Revised policy number MA00.033b was issued as a result of annual policy review/coding update.

The following CPT codes have been added to Attachments A, B and C with the 01/01/2016 annual coding update:
0403T, A4337

The following CPT code has been added to Attachments A and C, effective 01/01/2016: 86580

The following CPT code has been added to Attachments A, effective 03/18/2016: 92570

The following CPT code on Attachments B had a delete date of 10/01/2005. Effective 03/18/2016, the CPT codes were re-added:
94664, 95145, 95146, 95147, 95148, 95149, 95165, 95170

For Medicare Advantage only:
Service codes 99384, 99385, 99386, 99387, 99394, 99395, 99396, and 99397 when billed with ICD-9 codes V72.31 and V72.32 are termed effective 03/07/2016.

The following codes will be indicated as PCP Bill-Aboves on the Master Grid for all states, because they are categorized as injectable drugs or vaccines. These codes will not appear in the policy document.

90625, E0465, E0466, E1012, J0202, J0596, J0695, J0714, J0875, J1443, J1447, J1575, J1833, J2407, J2502, J2547, J2860, J3090, J3380, J7121, J7188, J7205, J7313, J7328, J7340, J7503, J7512, J7999, J8655, J9032, J9039, J9271, J9299, J9308, Q9980

REVISIONS FROM MA00.033a:
01/02/2015This is a coding update.

REVISIONS FROM MA00.033:
01/01/2015This is a new policy.






Version Effective Date: 08/19/2019
Version Issued Date: 08/19/2019
Version Reissued Date: N/A