Commercial

Medical Policy

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:

This 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.

Title:

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

Policy #:

00.10.01an

Policy

State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

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. In addition, PCPs are eligible to receive reimbursement above capitation for the administration of injectable drugs and vaccines.

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 and B that 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 and B 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.

HMO and 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

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

See Attachments A and B.

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.10.01an:

04/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2026.

HCPCS code A4318 has been added to Attachment A and B of the policy.

Revisions From 00.10.01am:

01/01/2026

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2026.

The following CPT/HPCS codes have been added to Attachment A and B of this policy:

A4295, A4296, A4297, 87812, and 90481

The following CPT/HCPCS codes on attachment A of this policy have undergone narrative revisions of this policy:

A4351 and A4352

The following CPT/HPCS codes on attachment B of this policy have undergone narrative revisions:

10040, A4351, and A4352

Revisions From 00.10.01al:

11/26/2025

This policy has been reissued in accordance with the Company's annual review process.

01/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2025.

The following procedure codes have had narrative revisions:

97811, 97814, 98960, 98961 and 98962

Revisions From 00.10.01ak:

01/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024.

The following procedure codes has had narrative revisions:

99306, 99308

Revisions From 00.10.01aj:

10/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2023.

The following procedure code has had a narrative revision:

A4344

Revisions From 00.10.01ai:

07/03/2023

This version of the policy will become effective 07/03/2023. This policy has been updated to allow Depression screening to be reimbursed above the capitated rate to primary care providers (PCP).

Procedure code G0444 has been added to policy Attachments A and B.

Revisions From 00.10.01ah:

04/01/2023

This version of the policy will become effective 04/01/2023. This policy has been updated to allow Respiratory Syncytial Virus (RSV) and Streptococcus services to be reimbursed above the capitated rate to PCP's. In addition, the following language has been added Primary care providers (PCPs) are eligible to receive reimbursement above capitation for the administration of injectable drugs and vaccines.

The following CPT codes have been added to Attachments A & B of this policy:

87634, 87651 and 87807

In addition, this policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2023

The following CPT codes have been deleted from this policy:

G2023

Revisions From 00.10.01ag:

11/07/2022

This version of the policy will become effective 11/07/2022.

This policy has been updated to allow Advance Care Planning (ACP) to be reimbursed above the capitated rate to PCP.

Procedure codes 99497 and 99498 have been added to policy Attachments A and B.

Revisions From 00.10.01af:

03/01/2022

This version of the policy will be retro effective 03/01/2022. This policy has been updated to allow Fundus Photography (Technical Component only) to be reimbursed above the capitated rate to PCP.

Procedure code 92250-TC has been added to policy Attachments A and B

The effective date for procedure code U0002 has been updated from 12/13/2020 to 09/17/2020 to clarify the actual date the code was considered above capitation to PCPs.

Revisions From 00.10.01ae:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 1/01/2022.

The following procedure codes has had a narrative revisions:

21315 and 87426

Revisions From 00.10.01ad:

01/1/2021

This policy has been identified for the Annual Code Update. This version of the policy will become effective 01/01/2021.

The following codes have been added to Attachments A and B: 92650, 92651, 92652, 92653, 92229, 87426

The following codes have been revised in Attachments A and/or B: 92227, 99354, 99355, 99356

The following codes have been deleted from Attachments A and B: 92585, 92586

Revisions From 00.10.01ac:

12/14/2020

This version of the policy will become effective 12/14/2020.

Due to the COVID-19 Public Health Emergency, this policy is being updated as an off-cycle Code Update.

The following COVID-19 diagnostic testing and specimen collection codes are being added to this policy:

The following codes have been added to Attachments A and B: 0202U, 0240U, 0241U, 87428, 87635, 87636, 87637, 87811, G2023, U0002

Revisions From 00.10.01ab:

08/19/2019

This 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.

Revisions From 00.10.01aa:

01/02/2019

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

Revisions From 00.10.01z:

01/01/2019

This 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:

4/1/2026

Version Issued Date:

7/14/2026

Version Reissued Date: