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Medicaid rate increase for Primary Care Services


Federal law requires state Medicaid agencies to increase payments to the Medicare rate for primary care physician providers for Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes 99201-99499, and services related to immunization administration for vaccines and toxoids with CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, 90474, or their successor codes, for dates of service on or after January 1, 2013 through December 31, 2014.

Eligible Providers:

The rate increases apply to primary care services provided by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. Sub-specialists within the specialty designations for physicians of family medicine, general internal medicine, and pediatric medicine as recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association may also be eligible for increased payment.

Please note: The increased payment applies to services paid through both fee for service and managed care. Please contact the Managed Care health plan you are contracted with for information regarding their payment requirements.

To be eligible:

1. The provider must be board certified in the above listed specialties; or

2. If not board certified, at least sixty percent (60%) of the services billed by the physician for calendar year 2012 must be for primary care E/M codes 99201-99499 or their successor codes and vaccine administration codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, 90474.

3. For newly enrolled non-board certified physicians, claims data from calendar year 2013 will be reviewed retrospectively to ensure eligibility criteria are met before continuing the rate increase for 2014. If the retrospective review indicates that eligibility criteria described in #2 above has not been met, the increased payments made during 2013 will be recouped.

4. If the condition of eligibility to receive the payment rate increase is not met, the payment will no longer be made.

Physicians delivering primary care services at Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs) are not eligible for increased payments under federal law.

Services performed by a physician assistant or advanced registered nurse practitioner

Primary care services performed by a physician assistant or advanced registered nurse practitioner under direct supervision of a physician according to the respective provider handbook policies, may be billed with the supervising physicians rendering provider number who attests to having the specified primary care specialists or claim volumes. There is no increase in payment for independently practicing non-physician practitioners.

The Centers for Medicare and Medicaid Services (CMS) has requested states to submit the Medicaid State Plan Amendment that allows for this increase after January 1, 2013. States are required to have in place procedures for self-attestation by providers before enhanced payment is made.

The Medicaid fiscal agent is modifying the system to allow payment for the increase once attestations are received. Providers are encouraged to monitor the fiscal agent website for the attestation form that will be posted soon. This must be received by the fiscal agent before the enhanced payment can be reimbursed.


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