Primary Care Physician Enhanced Rates
Effective January 1, 2013, qualified Primary Care Physicians as detailed by CMS regulation are to receive a rate increase effective until 12/31/14. This rate increase is also referred to as the “PCP Bump”. This rate increase also includes payments for services furnished by Primary Care Physicians under the Vaccines for Children program. Payments to Primary Care Physicians are being made to designated providers for current claims from the Managed Care Contractors. Managed Care Organizations are also beginning the process of making retroactive rate adjustments for qualified providers. Increased payment for physician crossover services from TennCare will begin once required system changes are complete. Physician crossover payments related to these rate increases are currently targeted for January 2014 and will include retroactive payments for eligible providers for eligible services back to January 2013. To see the latest CMS Q&A .
The enhanced reimbursement rates for qualified providers are effective for dates of service on and after January 1, 2013 through December 31, 2014. MCOs will begin to pay enhanced rates to most qualified providers for current dates of service effective August 1, 2013. Please look for information from your MCO or check their websites (see links below) regarding provider types that may be delayed due to the MCOs system configuration requirements1. In the coming months, all MCOs will begin to reprocess affected claims for retroactive dates of service as described below.
TennCare MCOs have prepared and sent notices to their contracted providers that have been identified in one of the eligible specialties/subspecialties that may qualify for the PCP enhanced rate. If you have received one of these notices, PLEASE READ IT CAREFULLY and follow any instructions that are contained therein. (If you also bill TennCare for Medicare/Medicaid crossover payments, your MCO will provide us with your qualifying information.) If you have NOT received a notice from the TennCare MCO(s) you are contracted with by May 15, 2013 and think you are eligible, please contact each of the MCOs you are contracted with or visit their website to obtain their MCO specific Attestation Form and instructions.
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IF you do not bill or do not have a contract with an MCO but you bill TennCare directly for Medicare cross over payments and think you qualify, please complete the TennCare Attestation Form for Crossover ONLY Providers at www.tn.gov/tenncare/forms/TN1202Self-AttestationForm.pdf in order to receive the enhanced rates. See an example on how to fill out the Attestation Form .
Please note the following key points:
If you are board certified in an applicable specialty, please complete all related fields on the Attestation Form identifying the specific board specialty, dates and signatures.
If you are attesting based on the 60% claims threshold, please note this requirement applies to your total eligible Medicaid services, statewide.
If you supervise and are professionally responsible for mid-level practitioners in your office, you must complete all requested information on the Attestation Form for each in order for him/her to be eligible for the enhanced payment.
In order to receive the enhanced rates retroactive to dates of service on and after January 1, 2013, we must receive your completed attestation form by July 15, 2013. For forms received after this date, payments will be adjusted retroactively only for dates of service on or after the date the form was received by an MCO or TennCare (if you are not contracted with an MCO). Please note that if incomplete forms are received, you will be notified; however, we cannot guarantee that you will be notified in time for you to return a completed form by the July 15, 2013 deadline.
For retroactive processing, you will not have to resubmit eligible claims. Once the implementation date is established, MCOs and TennCare will identify the eligible claims, based on the CPT codes noted in the regulations, and adjust payments to the greater of your contractual rates or the increased rate specified in regulation and the CMS approved TennCare State Plan Amendment.
If You Have A Contract With A TennCare MCO, Please Follow Their Instructions Carefully.
If you contract with more than one TennCare MCO, you must follow the instructions provided by each MCO and complete the Attestation Form provided by your MCO. However, if you contract with at least one TennCare MCO AND file Medicare Crossover claims with TennCare, you do NOT have to take any further action directly with the Bureau of TennCare as we will obtain your qualifying information from your MCO.
To see the Medicare Primary Care Provider Enhanced Rates that apply to Qualified Providers for the specified procedure codes that will be effective January 1, 2013 through December 31, 2014.
Thank you for your assistance in providing the best quality care for our members.
1. UnitedHealthcare Community Plan will be ready to pay new day claims for the PCP enhanced payment initiative beginning August 1, 2013, with the exception of the following specialty types; mid-level / non-physician practitioners practicing under the supervision of an eligible physician (e.g., nurse practitioners, physician assistants and nurse mid-wives) and eligible hospital-based providers who bill the eligible E&M and vaccine administration codes, which may include hospitalists, neonatologists and emergency medicine/critical care specialists. UnitedHealthcare Community Plan will be ready to pay new day claims for eligible providers in these specialties by September 1, 2013.