HPSA bonus pay policy information
For claims with dates of service on or after Jan. 1, 2009, only services furnished in areas designated as a Health Professional Shortage Area (HPSA) as of Dec. 31 of the prior year are eligible for the HPSA bonus payment.
Services furnished in areas designated at any time during the current year will not be eligible for the HPSA bonus payment until the following year, provided they are still designated on Dec. 31.
If you are providing services to Medicare beneficiaries in areas designated on Dec. 31 of the prior year but not included on the list of zip codes eligible for automated HPSA bonus payments, make certain you use the AQ modifier to get the HPSA bonus payment. Services submitted with the modifier will be subject to post-payment review.
The Medicare contractor will automatically make a 10 percent HPSA bonus payment to physicians providing eligible services in a ZIP code included in the annual file. Only physicians’ professional services are eligible for the bonus payment. The technical component of diagnostic services and services that are fully technical are not eligible. Determination of the bonus payment will be made based on the zip code where the service was rendered, not the zip code of the physician’s office.
Access the Centers for Medicare & Medicaid Services (CMS) Web page for HPSA here. The bottom of the Web page (Downloads) has information to help you determine if you are eligible for the bonus and whether or not you need to append the AQ modifier.
For the zip-code files for 2009, visit here and here.
Internet-based PECOS
CMS has established an Internet-based Medicare provider/
supplier enrollment process, known as Provider Enrollment, Chain and Ownership System (PECOS). This process will allow physicians and non-physician practitioners the option of enrolling, making a change in their Medicare information, or tracking the status of their Medicare applications throughout the enrollment process. For additional information regarding Internet-based PECOS, go to the download section here.
The second link, contains contact information. You can report application navigation or access problems with PECOS, get help establishing a National Plan and Provider Enumeration System (NPPES) User ID and password or assistance changing an NPPES password. Contact the EUS Help Desk if you have a valid NPPES User ID and password but are not able to access PECOS.
The third link, is the getting started guide.
The last link on the Web page, “Related Linked Outside CMS,” is here.
Internet-based PECOS supports most Medicare enrollment application actions with some limitations. A physician or non-physician practitioner cannot use PECOS to:
- Change his/her name or Social Security Number.
- Change an existing business structure. For example:
- – A sole owner of an enrolled professional association, professional corporation, or LLC cannot change the business structure to a sole proprietorship
- – An enrolled sole proprietorship cannot be changed to a solely-owned professional association, professional corporation, or LLC
- Reassign benefits to another supplier if that supplier does not have a current Medicare PECOS record
PECOS users still need to sign and date the Certification Statement and mail it and all supporting paper documentation to the Medicare contractor.
Note: A Medicare contractor will not process an Internet enrollment application without the signed and dated Certification Statement and the required supporting documentation. The effective date of a filed enrollment application is the date the Medicare contractor receives the signed Certification Statement. The physician or non-physician practitioner enrolling or making changes to enrollment information must sign the statement. Signatures must be original and in ink (blue preferred). Copied or stamped signatures will not be accepted.
Influenza and pneumococcal vaccines
Payment allowances for influenza vaccines are updated annually, effective Sept. 1 of each year. Payment allowances for pneumococcal vaccines are updated quarterly. Change Request (CR) 6153 provides the payment allowances for Current Procedural Terminology (CPT) codes 90655, 90656, 90657, 90658 and 90660, as well as pneumococcal vaccines CPT codes 90732 and 90669 when payment is based on 95 percent of the average wholesale price (AWP).
Effective September 2008, Medicare Part B payment allowances for influenza vaccines appear in the table below.
| CPT Code |
Allowance |
| 90655 |
$16.879 |
| 90656 |
$18.198 |
| 90657 |
$6.609 |
| 90658 |
$13.218 |
CPT 90660 for FluMist, a nasal influenza vaccine, may be covered if the local Medicare claims processing contractor determines its use is medically reasonable and necessary for the beneficiary. When payment is based on 95 percent of the AWP, the Medicare Part B payment allowance for CPT 90660 is $22.316. G0008, G0009 and G0010 are no longer based on 90471; they have their own fee schedule here.
The Medicare Part B payment allowance for the pneumococcal vaccine CPT code 90732 is $32.703, and for CPT code 90669, it is $78.803. These payment allowances were published as a part of the July 2008 Quarterly Average Sales Price (ASP) Drug Pricing Files, as specified in CR6049. To view more information about CR 6049, see here.
Annual Part B deductible and co-insurance amounts do not apply to these vaccines. Physicians, non-physician practitioners and suppliers who administer influenza virus and pneumococcal vaccinations must take assignment for vaccines on the claims.
HBV vaccine
Medicare provides coverage for the hepatitis B virus (HBV) vaccine and its administration for certain beneficiaries at intermediate to high risk for HBV.
To learn who should receive these vaccines, see here.
Contractor survey
CMS will distribute the 2009 Medicare Contractor Satisfaction Survey to a sample of approximately 30,000 randomly selected Medicare providers across the country. CMS has already notified providers selected to participate. If you were selected, you are urged to submit your responses via a secure Web site, mail, fax or over the phone.
The survey offers you the opportunity to contribute to CMS’s understanding of Medicare contractor performance, and to aid future process improvement efforts at the contractor level. All Medicare Administrative Contractors (MACs) will be measured against performance targets on the 2009 survey.
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Hoosier Healthwise Open Enrollment
To enhance continuity of care, the Hoosier Healthwise program will begin Open Enrollment effective March 1, 2009. Currently, Hoosier Healthwise members can change their health plans at any time. Under Open Enrollment, members can change health plans only at the following times:
- Any time during their first 90 days enrolled with a new health plan
- Annually during their open enrollment period
- Any time there is “just cause” (for example, quality of care concerns)
Provider maintenance on Web Interchange
Using Web interchange, providers can make profile updates. To make changes, visit here.
Provider enrollment
As of Jan. 1, physicians can enroll in the IHCP using the Internet rather than completing paper forms and mailing them. You can quickly and easily enroll as a new billing or group provider using a Web-based enrollment tool. Only newly enrolled providers may use the enrollment tool at this time.
Medical Review Team
In accordance with Indiana law regarding outpatient mental health services, outreach from EDS provider representatives will be forthcoming to psychiatrists, licensed physicians, and other psychology health service providers.
An update on MRT claims that are in a suspended status will be provided and a bulletin regarding this information will be published in the future.
EPSDT Program
The Indiana HealthWatch Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program offers preventive health care for members under age 21. The purpose of the program is to assist with abnormalities that may become chronic or debilitating.
EPSDT periodic medical screenings are conducted at regular intervals during a child’s life up to the 21st birthday for Medicaid-eligible children and up to the 19th birthday for a child in Package C.
If the member is in a Hoosier Healthwise risk-based managed care (RBMC) network, the member’s MCO can provide information. Refer to the HealthWatch EPSDT Provider Manual for further information.
Provider workshops
IHCP workshops to be held during first quarter 2009 include the Medical Review Team presented by EDS, Hoosier Healthwise Open Enrollment presented by EDS and the three MCOs, and IHCP Updates presented by EDS.
Dates and locations for 2009 are:
- Fort Wayne - Feb. 17
- Indianapolis - Feb. 23
- Valparaiso - Feb. 25
- Elkhart - Feb. 26
- Kokomo - March 3
- Lawrenceburg - March 10
- Terre Haute - March 19
- Evansville - March 24
- Muncie - March 31
Wards and fosters
Effective Jan. 15, 2009, the Office of Medicaid Policy and Planning (OMPP) completed auto-assignment of wards of the court and foster children into Indiana Care Select. New enrollees in the IHCP have 30 days from the date of their initial eligibility to select primary care providers (PMPs) or be auto-
assigned to Care Select PMPs. A Care Select member’s guardian or caregiver can contact the member’s assigned CMO to select a different Care Select PMP at any time.
Continuity of care
Care Select PMPs are reminded that their new members may already be receiving care from IHCP-enrolled specialists, hospitals, ancillary providers or previous PMPs. A PMP who ordered services prior to the Jan. 15, 2009, auto-assignment effective date may not be the same PMP a member is assigned to after Jan. 15, 2009.
The OMPP and the CMOs are asking newly assigned PMPs to work with the member’s previous PMP and other providers to ensure continuity of care. If care has already been initiated for a member, review the member’s medical record and authorize the continuation of that care until the member can become an established patient with your practice.
You can authorize care by releasing your quarterly two-character certification code and National Provider Identifier (NPI) to these providers so they may be reimbursed for their services.
All providers are encouraged to visit each CMO’s Web site for additional information related to Care Select and the transition of wards and foster children to Care Select. Go to:
- Here for MDwise Care Select
- Here for ADVANTAGE Care Select
Also see the following bulletins:
- BT200723-Indiana Care Select dated Sept. 13, 2007
- BT200804-Updated Indiana Care Select and Prior Authorization and Restricted Card Changes dated Jan. 15, 2008
Contact information
If you have questions, please contact Customer Assistance at (317) 655-3240 in the Indianapolis local area or tollfree at (800) 577-1278. Find contact information for managed care entities on the IHCP Provider Quick Reference page here.
The next meeting is scheduled for
March 13, 2009.
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