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Primary Care Incentive Payment Program (PCIP) Eligibility for New Providers Enrolled in Medicare


Definitions for Primary Care Practitioners (PCP) and Primary Care Services

In the case of new providers enrolled in Medicare in the year immediately preceding the PCIP payment year who do not have claims data from 2 years prior to the PCIP payment year upon which an eligibility determination can be made, PCIP eligibility will be determined using only the most recent prior year claims data available with no minimum time period that the potential primary care practitioner must have been enrolled in Medicare. Therefore, newly enrolled potential primary care practitioners would need to wait no more than one year following their enrollment and first billing in order for the primary care services furnished by eligible primary care practitioners to be subject to the PCIP in the year following the practitioner’s initial enrollment.

Due to the processing lag for claims data for the previous calendar year (CY), PCIP eligibility determinations for newly enrolled primary care practitioners will be delayed until after the end of the PCIP payment year. Although PCIP payments will ultimately be made for all primary care services the eligible practitioners furnished throughout the full PCIP payment year. Therefore, a single cumulative PCIP payment for newly enrolled primary care practitioners will be based on eligible services rendered from January 1 through December 31 of the payment year, and will be made following the fourth quarter of the incentive payment year.

CMS will provide contractors with two data files. First, the “PCIP Payment for New Providers Enrolled in Medicare File” will list all eligible, newly enrolled primary care practitioners by national provider identifier (NPI) and will be used to identify practitioner eligible for PCIP payment. Second, “PCIP Inquiry for New Providers Enrolled in Medicare File” will list all newly enrolled Medicare practitioners and their percentage of primary care services to be used for inquiries. Files will be available in October of the PCIP payment year.

If a claim for a primary care service is submitted by a physician or group practice, the primary care professional service must be reported under a practitioner with a qualifying NPI in order for the service to qualify for the incentive payment. The PCIP payments will be calculated by the Medicare contractors and the single cumulative PCIP payment for newly enrolled primary care practitioners will be made following the fourth quarter and will reflect eligible PCIP services furnished from January 1 thru December 31 of the PCIP payment year. Newly enrolled primary care practitioners who receive the PCIP payment under this provision are not assured eligibility for PICP payment in subsequent years, as primary care practitioners need to qualify for the PCIP each year.

Important points:

CMS shall provide contractors, on an annual basis, with a “PCIP Payment for New Providers Enrolled in Medicare File” which will list all qualifying newly enrolled Medicare NPIs and “PCIP Inquiry for New Providers Enrolled in Medicare File” which will list all newly enrolled Medicare providers.

For newly eligible primary care practitioners listed on the “PCIP Payment for New Providers Enrolled in Medicare File”, contractors shall make the single cumulative PCIP payments after the fourth quarter of the payment year.

Contractors shall base the single cumulative PCIP payment for newly enrolled primary care practitioners on eligible services rendered from January 1 through December 31 of the payment year.

Contractors shall base any subsequent PCIP payments for newly enrolled primary care practitioners on one quarter’s worth of eligible claims and make quarterly payments as long as the primary care practitioner remains eligible. Note: PCIP eligibility is established annually

Payment of the incentive shall be made to the individual or group following normal claims payment protocol.

For each qualifying NPI on the “PCIP Payment for New Providers Enrolled in Medicare File,” contractors shall accumulate the total paid amount (or review paid claims history) for codes 99201 through 99215, and 99304 though 99350 for all four quarters of the payment year.

For each payment contractors shall calculate a payment equal to 10 percent of the amount paid each for CPT codes 99201 through 99215, and 99304 though 99350, billed by the PTANs associated with each qualifying NPI listed on the “PCIP Payment for New Providers Enrolled in Medicare File.”

The incentive payment is based on the amount paid, and not the Medicare approved amount.

Contractors shall use the special incentive remittance that is currently used for the HPSA physician bonus payment program to include other incentive payments so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for each incentive program.

Contractors shall pay the single cumulative PCIP payment for newly enrolled practitioners at the same time and on the same check as the HPSA physician bonus. Note: The single incentive payment will be made in January, following the PCIP program eligibility year.

Method of PCIP Payment

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