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ACA Primary Care Physician Rate Increase: Retroactive Payments

June 17, 2014

On April 11, 2014, the “ACA Rate Increase for Specified Primary Care Services Implementation Update” announced new Patient Protection and Affordable Care Act (ACA)-specific modifiers that are available for use and provided a crosswalk for the use of the modifiers. The Department of Health Care Services (DHCS) understands that some ACA-eligible claims using local codes have already been submitted and paid without the ACA increase. Eligible claims will be reprocessed retroactive to January 1, 2013, to apply these enhanced payments.

To ensure that these retroactive payments are implemented in the most efficient and expeditious manner, a new process has been developed. Affected providers may refer to the Patient Protection and Affordable Care Act: Retroactive NICU/PICU Claim to ACA Modifier Assignment Instructions (PDF) for information about the new process and instructions for completing and submitting the NICU/PICU Claim To ACA Modifier Assignment Spreadsheet template (Excel format). Providers who follow this new process will not need to submit a Claim Inquiry Form (CIF) to adjust their claims.


Providers who prefer using the standard claim adjustment process may continue to submit a CIF with the applicable ACA modifier to recover any incremental difference in payment and do not need to follow the new process.

For more information about the ACA increased Medicaid payments for primary care physicians, please visit the ACA Increased Medicaid Payment for Primary Care Physicians page of the Medi-Cal website.