Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issued Date: N/A

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.

Policy Attachment

Attachment to Policy #

MA00.033o

Attachment:

A: PENNSYLVANIA

Policy #:

MA00.033o

Description:

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

Title:

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

PENNSYLVANIA (PA)
SERVICES PAID ABOVE CAPITATION FOR HEALTH MAINTENANCE ORGANIZATION (HMO) AND HEALTH MAINTENANCE ORGANIZATION POINT-OF-SERVICE (HMO-POS) PRIMARY CARE PHYSICIANS (PCPs)

NOTES:

The Effective Date indicates either the effective date of the code and/or the date the code became eligible for payment above capitation.

The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer eligible for reimbursement above capitation.

PA PCPs are eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules. Injectable drug and vaccine codes are not included in the code list below.

PA PCPs are eligible to receive payment above capitation for select Durable Medical Equipment and Supplies, such as cast/splints, crutches, and canes. Durable Medical Equipment and Supplies are not included in the code list below.

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code	Effective Date	Delete Date
0403T	01/01/2016
0202U	12/14/2020
0240U	12/14/2020
0241U	12/14/2020
10060	12/01/08
10061	01/01/10
10080	12/01/08
10140	12/01/08
10160	12/01/08
11200	03/01/03
11201	01/01/09
11400	03/01/03
11401	03/01/03
11402	03/01/03
11403	03/01/03
11404	03/01/03
11406	03/01/03
11420	01/01/10
11421	01/01/10
11422	01/01/10
11423	01/01/10
11424	01/01/10
11426	01/01/10
11440	01/01/10
11441	01/01/10
11442	01/01/10
11443	01/01/10
11444	01/01/10
11446	01/01/10
11600	01/01/10
11601	01/01/10
11602	01/01/10
11603	01/01/10
11604	01/01/10
11606	01/01/10
11620	01/01/10
11621	01/01/10
11622	01/01/10
11623	01/01/10
11624	01/01/10
11626	01/01/10
11640	01/01/10
11641	01/01/10
11975	08/04/00	12/31/11
11976	08/04/00
11977	08/04/00	12/31/11
12001	03/01/03
12002	03/01/03
12004	03/01/03
12005	03/01/03
12006	03/01/03
12007	03/01/03
12011	03/01/03
12013	03/01/03
12014	03/01/03
12015	03/01/03
12016	03/01/03
12017	03/01/03
12018	03/01/03
12020	03/01/03
12021	03/01/03
17000	03/01/03
17003	03/01/03
17004	03/01/03
17110	01/01/08
17111	01/01/08
20550	03/01/03
20600	12/01/08
20604	01/01/15
20605	12/01/08
20606	01/01/15
20610	12/01/08
20611	01/01/15
31500	02/10/97
32421	01/01/08	01/01/13
36510	02/10/97
36620	02/10/97
36660	02/10/97
45330	03/01/03
45331	03/01/03
46916	03/01/03
46924	03/01/03
51100	01/01/08
51701	04/18/05
51702	04/18/05
51703	04/18/05
54000	08/01/01
54001	08/01/01
54056	03/01/03
54150	02/10/97
54160	02/10/97
56501	03/01/03
56515	03/01/03
57061	03/01/03
57065	03/01/03
57452	03/01/03
57454	03/01/03
57511	03/01/03
58100	03/01/03
58300	08/04/00
58301	08/04/00
86580	01/01/2016
86710	11/01/01
87275	08/19/2019
87276	08/19/2019
87400	08/19/2019
87426	06/25/2020
87428	12/14/2020
87501	08/19/2019
87502	08/19/2019
87503	08/19/2019
87634	04/24/2023
87635	12/14/2020
87636	12/14/2020
87637	12/14/2020
87651	04/24/2023
87804	01/01/02
87807	04/24/2023
87811	12/14/2020
87880	06/01/07
87899	11/01/01
90460	01/01/11
90461	01/01/11
90465	01/01/07	01/01/11
90466	01/01/07	01/01/11
90467	01/01/07	01/01/11
90468	01/01/07	01/01/11
90470	09/28/09	09/22/10
90471	01/01/07
90472	01/01/07
90473	01/01/07
90474	01/01/07
92227	10/01/17
92229	01/01/21
92250 - TC*	03/01/22
92550	01/01/10
92567	03/01/03
92570	01/01/10
92585	01/01/02	01/01/21
92586	01/01/02	01/01/21
92587	01/01/02
92588	01/01/02
92650	01/01/21
92651	01/01/21
92652	01/01/21
92653	01/01/21
94010	08/01/12
94640	03/01/03
94664	03/01/03
95145	02/10/97
95146	08/01/01
95147	08/01/01
95148	08/01/01
95149	08/01/01
95165	02/10/97
95170	02/10/97
96127	01/01/15
97802	07/01/07
97803	07/01/07
97804	07/01/07
98960	08/01/08
98961	08/01/08
98962	08/01/08

*For procedure code 92250 only the Technical Component will be reimbursed above capitation to PCPs. Procedure code 92250 must be appended with the TC modifier to represent the technical component.

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code	Diagnosis Code	Effective Date	Delete Date
99078		08/01/08
99170		08/01/01
99188		01/01/15
99217		01/01/09
99218		01/01/09
99219		01/01/09
99220		01/01/09
99221		06/01/06
99222		06/01/06
99223		06/01/06
99224		01/01/11
99225		01/01/11
99226		01/01/11
99231		06/01/07
99232		06/01/07
99233		06/01/07
99234		01/01/09
99235		01/01/09
99236		01/01/09
99238		06/01/06
99239		06/01/06
99291		08/01/01
99292		08/01/01
99295		02/10/97	12/31/08
99296		02/10/97	12/31/08
99297		02/10/97	12/31/03
99301		08/01/01	12/31/05
99302		08/01/01	12/31/05
99303		08/01/01	12/31/05
99304		01/01/06
99305		01/01/06
99306		01/01/06
99307		01/01/06
99308		01/01/06
99309		01/01/06
99310		01/01/06
99311		08/01/01	12/31/05
99312		08/01/01	12/31/05
99313		08/01/01	12/31/05
99315		01/01/06
99316		01/01/06
99318		01/01/06
99321		08/01/01	12/31/05
99322		08/01/01	12/31/05
99323		08/01/01	12/31/05
99324		01/01/06
99325		01/01/06
99326		01/01/06
99327		01/01/06
99328		01/01/06
99331		08/01/01	12/31/05
99332		08/01/01	12/31/05
99333		08/01/01	12/31/05
99334		01/01/06
99335		01/01/06
99336		01/01/06
99337		01/01/06
99341		10/01/94
99342		10/01/94
99343		10/01/94
99344		08/01/01
99345		08/01/01
99347		10/01/94
99348		10/01/94
99349		10/01/94
99350		08/01/01
99384	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99385	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99386	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99387	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99394	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99395	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99396	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99397	Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation	10/01/04
99431		02/10/97	12/31/08
99436		02/10/97	12/31/08
99440		08/01/01	12/31/08
99460		01/01/09
99461		01/01/09
99462		01/01/09
99463		01/01/09
99464		01/01/09
99465		01/01/09
99468		01/01/09
99469		01/01/09

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code	Effective Date	Delete Date
A4310	04/18/05
A4311	04/18/05
A4312	04/18/05
A4313	04/18/05
A4314	04/18/05
A4315	04/18/05
A4316	04/18/05
A4326	08/01/08
A4327	08/01/08
A4328	08/01/08
A4333	04/18/05
A4334	04/18/05
A4336	01/01/10
A4337	01/01/2016
A4338	04/18/05
A4340	04/18/05
A4344	04/18/05
A4346	04/18/05
A4348	04/18/05	01/01/07
A4349	04/18/05
A4351	04/18/05
A4352	04/18/05
A4353	04/18/05
A4354	04/18/05
A4357	04/18/05
A4358	04/18/05
A4359	04/18/05	01/01/07
A4360	01/01/10
A5056	01/01/12
A5057	01/01/12
A5102	04/18/05
A5105	04/18/05
A5112	04/18/05
A5113	04/18/05
A5114	04/18/05
A5200	04/18/05
G0008	01/01/07
G0009	01/01/07
G0010	01/01/07
G0108	08/01/08
G0109	08/01/08
G0270	07/01/07
G0271	07/01/07
G0444	07/03/2023
G2023	12/14/2020	03/31/2023
G9141	09/15/09	09/22/2010
S0610	07/01/03
S0612	07/01/03
S8930	01/01/19
S9140	08/01/08
S9141	08/01/08
S9449	07/01/07
S9452	07/01/07
S9455	08/01/08
S9460	08/01/08
S9465	08/01/08
S9470	07/01/07
U0002	09/17/2020

Version Effective Date:

10/01/2023

Version Issued Date:

10/18/2023

Version Reissued Date:

N/A