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TO: All Physician Providers
Reminder: In order to continue to receive the Primary Care Enhanced Physician Rates for 2015, you must reattest by 01/31/2015. See below.
Medicaid-enrolled primary care physicians who qualify for Primary Care Enhanced Physician Rates may continue to receive enhanced payments after the federal program ends on December 31, 2014.To qualify, eligible1 providers must accurately self-attest by filing required 2015 forms following the procedures below.
The current approval for the enhanced rates includes dates of service January 1, 2015 through September 30, 2015.
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 they actually 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 eligible1 if he/she can attest that 60 percent of their paid Medicaid procedures billed are for certain specified1 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 eligible1 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
5. OB/GYNs
6. Nursing Facility
Where can a provider go to view the Primary Care Enhanced Physician Rates?
A provider can visit http://www.medicaid.alabama.gov/documents/6.0_Providers/6.6_Fee_Schedules/6.6_Physician_ACA%20_Primary_Care_Fee_Schedule_Revised_3-1-14.pdf for the 2015 procedure codes and fees.
What steps are necessary for a provider to be eligible1 Primary Care Enhanced Physician Rates?
1. Visit http://www.medicaid.alabama.gov/
2. Select Provider Enrollment from the drop-down menu under “Providers”
3. Complete a 2015 self-attestation form
4. Attach proof of board certification, if applicable
5. Mail original self-attestation form to the address specified
When will the provider receive the Primary Care Enhanced Physician Rates?
1. An eligible1 provider with 2015 self-attestation form on file at HPES by January 31, 2015, will receive payment at the enhanced rates retroactive to January 1, 2015.
2. An eligible1 provider with 2015 self-attestation form on file at HPES on or after February 1, 2015, will receive payment at the enhanced rates for dates of service beginning with the date of the self-attestation is entered into the system by HPES.
The Agency will review and verify that requirements for the enhanced rates are being met. Enhanced rates paid to providers that do not meet the specifications1 may be subject to recoupment.
For questions regarding the primary care enhanced physician rates, please contact Beverly Churchwell at beverly.churchwell@medicaid.alabama.gov.
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