Notification

Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers


Notification Issue Date: 02/18/2019


This version of the policy will become effective 01/02/2019.

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



Claim Payment Policy


Title:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

Policy #:00.10.01aa

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The specific services that are listed in Attachments A, B, and C 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 Delaware PCPs
  • Attachment B applies to New Jersey PCPs
  • Attachment C applies to Pennsylvania 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.
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, B, and C which can be performed at the PCP's office.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, services that are outlined in Attachments A, B, and C are covered under the medical benefits of the Company’s 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, B, and C.
References


Company Benefit Contracts.




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, B, and C.


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, B, C.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

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

Attachment B: 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

Attachment C: 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



Policy History

00.10.01aa
01/02/2019This version of the policy will become effective 01/02/2019.

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 00.10.01z:
01/01/2019This version of the policy will become effective 01/01/2019.

Revised policy number 00.10.01z is being issued as a result of a medical benefit being offered for acupuncture services, effective 01/01/2019. Medically necessary acupuncture services will be reimbursed fee-for-service if performed by a PCP (including CRNP or PA practicing in primary care).

The following CPT and HCPCS codes have been added to Attachments A, B, C in this policy:

97810, 97811, 97813, 97814, S8930.

The following CPT code narratives have been revised in Attachments A, B, C in this policy as a result of the 01/01/2018 Annual Code Update.

99217, 99218, 99219, 99220


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/02/2019
Version Issued Date: 02/18/2019
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.