TO: All Physician Providers
Effective for dates of service October 1, 2016, Medicaid will resume enhanced
payments through the Alabama Medicaid Physician’s Primary Care Enhanced Rates
Which providers may qualify for the Primary Care Enhanced Physician Rates?
A provider must meet one of the following requirements listed below:
1. A provider must have a specialty or subspecialty designation in family medicine, general internal medicine, or pediatrics that is recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS), or the American Osteopathic Association (AOA), and practice in their specialty.
2. A NON-board certified provider who practices in the field of family medicine, general internal medicine, or pediatrics or a subspecialty under one of these specialties, is eligible(1) if he/she can attest that 60 percent of their paid Medicaid procedures billed are for certain specified(1) procedure codes for evaluation and management (E&M) services and certain Vaccines for Children (VFC) vaccine administration codes.
Note* Practitioners (physician assistants or certified registered nurse practitioners)
providing services under the personal supervision of eligible(1) physicians may qualify.
Which providers do NOT qualify for the Primary Care Enhanced Physician Rates?
Below are examples of providers who do not meet criteria:
1. Federally Qualified Health Center (FQHC)
2. Rural Health Clinic (RHC)
3. Health Department (ADPH)
4. Teaching Facility
6. Nursing Facility
Where can a provider go to view the Primary Care Enhanced Physician Rates?
A provider can visit www.medicaid.alabama.gov for procedure codes and fees.
What steps are necessary for a provider to be eligible(1) for the Primary Care
Enhance Physician Rates?
1. Visit www.medicaid.alabama.gov
2. Select Provider Enrollment from the drop-down menu under “Providers”
3. Complete a self-attestation form
4. Attach proof of board certification, if applicable
5. Mail original self-attestation form to the address specified
Note* All fields on the self-attestation form must be completed correctly.
For questions about how to fill out the self-attestation form, please contact and HPE
Provider Representative by visiting this link.
When will the provider receive the Primary Care Enhanced Physician Rates?
1. An eligible(1) provider with self-attestation form on file at HPE by October 31, 2016, will receive payment at the enhanced rates retroactive to October 1, 2016.
2. An eligible(1) provider with 2016 self-attestation form on file at HPE on or after November 1, 2016, will receive payment at the enhanced rates for dates of service beginning with the date the self-attestation is entered into the system by HPE.
The Agency will review and verify that requirements for the enhance rates are being
met. Enhanced rates paid to providers that do not meet the specifications(1) may be
subject to recoupment.
For questions regarding the primary care enhanced physician rates, please contact
Beverly Churchwell at firstname.lastname@example.org.
(1) As defined by 42 C.F.R.
Pts.438, 441, and 447, interpreted by Centers for Medicare and Medicaid (CMS)
guidance and consistent with the Alabama State Plan