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.
| MCO | Provider Services |
| Wellpoint (formerly known as Amerigroup) | 800-454-3730 |
| BlueCare | 800-468-9736 |
| UnitedHealthcare Community Plan | 800-690-1606 |
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.
Continue to visit your MCO’s for updated information, as well as Medicaid.gov.
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.
Do allergists qualify for higher Medicaid payment under this regulation?
CMS recently received information from the American Board of Medical Specialties attesting that the American Board of Allergy and Immunology (ABAI) is an ABMS-recognized subdiscipline of the American Board of Pediatrics and the American Board of Internal Medicine.
Specifically, the ABAI is a conjoint board of the American Board of Pediatrics (ABP) and the American Board of Internal medicine (ABIM). All physicians certified by the Board of Allergy and Immunology must first be board certified by either ABP or ABAI. Medical specialists certified by the Allergy and Immunology Board remain subspecialists of Internal Medicine and Pediatrics. However, it is possible that some holders of a certificate from ABAI will not have a current certificate in Internal Medicine or Pediatrics because some diplomats of the ABP and ABIM who hold subspecialty certificates are not required to maintain their primary certificates. The ABMS was concerned that these diplomats might be excluded from eligibility for higher payment under a strict interpretation of the rule even though they do act as their patients’ primary care provider in many cases and urged that CMS formally recognize that diplomats of ABAI are, in fact subspecialists in Internal Medicine and Pediatrics and eligible for higher payment up to the Medicare rate.
Based on this information, CMS agrees that allergists are eligible for higher payment under the rule.