Claims Processing and Payment

90.4.11.5 - Claims Processing and Payment (Rev. 2040, Issued: 08-27-10, Effective: 01-01-11 and 04-04-11, Implementation: 01- 03-11 for the claim identification of the incentive and 04-04-11 for full implementation) A. General Overview The HPSA physician bonus program guidelines are contained in Pub. 100-04, Chapter 12, §90.4. Refer to that section for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005. The following guidelines pertain only to the additional 10 percent incentive payment for 10 - or 90 - day global surgical procedures furnished by 02 - general surgeons in HPSAs from January 1, 2011 through December 31, 2015. A/B MACs (B) shall identify eligible surgical procedures with a 10 - or 90 - day global period rendered in an eligible primary care HPSA zip code area based on the HPSA physician bonus ZIP code file for the appropriate date of service. The HPSAs eligible for automatic payment may be found on the CMS Web site at: http://www.cms.gov/HPSAPSAPhysicianBonuses/01_overview.asp. A/B MACs (B) must also inform eligible practitioners about the use of modifier -AQ on claims for 10 - or 90 - day global surgical procedures that were furnished in HPSAs approved by December 31 of the preceding calendar year, but that are not recognized for automatic payment. The modifier must be appended to the surgical procedure for the service to be eligible for the 10 percent additional HSIP payment. B. Method of Payment • Calculate and pay general surgeons an additional 10 percent incentive payment; • Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount; • Combine the HSIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment; • Accept and pay the incentive payment for 10 - and 90 - day global period surgical procedures furnished by general surgeons (02) and submitted with the modifier - AQ; • Provide a special remittance form that is forwarded with the incentive payment so that physicians and nonphysician practitioners can identify which type of incentive payment (HPSA, HSIP, and/or PCIP) was paid for which services; • Use the PLB03 adjustment reason code LE; • Add the following message to the incentive checks: This check is for the HPSA, HSIP and/or PCIP. See special remittance for details; and • Inform practitioners to contact their A/B MAC (B) with any questions regarding HSIP payments. C. Changes for A/B MAC (B) Systems The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new incentive HPSA/PSA/HSIP/PCIP payment indicator on the claim line. Once the type of incentive has been identified by the shared systems, the shared system shall transmit the HPSA/PSA/HSIP/PCIP indicator to CWF and modify their systems to set the indicator on the claim line as follows: 1 = HPSA; 2 = PSA; 3 = HPSA and PSA; 4 = HSIP; 5 = HPSA and HSIP; 6 = PCIP; 7 = HPSA and PCIP; and Space = Not Applicable. The MCS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment. The A/B MAC (B) shall also combine the practitioner’s HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), HSIP payment, and/or PCIP payment invoice per practitioner. The A/B MAC (B) shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.