Medicare Advantage

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 #:

MA00.033s

Policy

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, primary care providers (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 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

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 MA00.033s:

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 MA00.033r:

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 MA00.033q:

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 for the Annual Code Update. This version of the policy will become effective 01/01/2025

The following codes have been revised in Attachments A and/or B:

97811, 97814, 98960, 98961 and 98962

Revisions From MA00.033p:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
01/01/2024	This policy has been identified for the Annual Code Update. This version of the policy will become effective 01/01/20234 The following codes have been revised in Attachments A and/or B: 99306 and 99308

Revisions From MA00.033o:

10/01/2023

This policy has been identified for the Annual Code Update. This version of the policy will become effective 10/01/2023

The following code has been revised in Attachments A and B:

A4344

Revisions From MA00.033n:

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
PCP's.

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

Revisions From MA00.033m:

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 to the policy, 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 MA00.033l:

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 MA00.033k:

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 captiation to PCP's.

Revisions From MA00.033j:

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 MA00.033i:

01/01/2021

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 MA00.033h:

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 MA00.033g:

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 MA00.033f:

01/01/2019

This 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:

12/01/2017

Physician 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:

10/01/2017

This 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:

08/01/2017

Certified 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:

03/18/2016

Revised 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:

01/02/2015

This is a coding update.

Revisions From MA00.033:

01/01/2015

This is a new policy.

Version Effective Date:

4/1/2026

Version Issued Date:

7/14/2026

Version Reissued Date: