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Claim Payment Policy
| Title: | Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians |
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Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, 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. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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 Intent |
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The intent of this policy is to communicate the services that are eligible for payment above the monthly capitation fee that is paid to Health Maintenance Organization (HMO) Primary Care Physicians (PCPs).
For information on policies related to this topic, refer to the Cross References section in this policy.
| Description |
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A Primary Care Physician (PCP) is a participating professional provider who is selected by a member and is responsible for providing all primary care covered services and for authorizing and coordinating all covered medical care, including referrals for specialist services.
Capitation is the reimbursement that a professional provider or participating facility receives in advance of services for Health Maintenance Organization (HMO) or HMO Point-of-Service (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 reimbursed as a set dollar amount.
HMO PCPs provide care that is medically necessary and preventive in nature. Generally, HMO 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. The services that are paid over and above the monthly capitation payments (above capitation) are listed in Attachments A, B, and C.
| Policy |
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The Company allows Health Maintenance Organization (HMO) Primary Care Physicians (PCPs) to receive reimbursement above capitation for the specific services that are listed in Attachments A, B, and C:
- Attachment A addresses Delaware
- Attachment B addresses New Jersey
- Attachment C addresses Pennsylvania
PCPs are also eligible to receive reimbursement above capitation for codes listed in the injectable drug and vaccine fee schedules.
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 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 |
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Laboratory testing by a Primary Care Physician (PCP) is processed by the PCP’s capitated outpatient laboratory, with the exception of the laboratory tests that are listed in Attachments A, B, and C.
BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contract, services that are outlined in Attachments A, B, and C are covered under the medical benefits of the Company’s products.
| References |
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Company Benefit Contracts.
Company Publications. Partners in Health Provider Manual. June 2004.
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| Coding Table |
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Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company. |
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| Code System | Code Number(s) and Narrative(s) |
| CPT | Refers only to HMO product line. See Attachments A, B, and C. |
| ICD Procedure | N/A |
| ICD Diagnosis | N/A |
| HCPCS Level II | Refers only to HMO product line. See Attachments A, B, and C. |
| Revenue Codes | N/A |
| Cross References |
| Associated attachments to Policy 00.10.01m: Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians |
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| Cross Reference Policies |
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| Version Effective Date: 07/01/2010 | |
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The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2010 AmeriHealth, Inc. All Rights Reserved. Current Procedural Terminology ©2010 American Medical Association. All Rights Reserved. |
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