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Update: ACA Primary Care Rate Increases

May 18, 2015

The Patient Protection and Affordable Care Act (ACA) required increases in the rates potentially payable to specified Primary Care Providers (PCP). Providers were given the opportunity to attest their eligibility and to potentially receive additional ACA payments for services.

Below are important updates for various ACA payment issues, including the opportunity to resubmit the Neonatal Intensive Care Unit/Pediatric Intensive Care Unit (NICU/PICU) “claim to ACA modifier” assignment spreadsheets, the decommissioning of the self-attestation website and the recoupment of excess ACA interim payments.

For additional background information regarding ACA increased rates, please refer to the ACA Increased Medicaid Payment for Primary Care Physicians page.

June 15, 2015: Second Opportunity to Re-submit NICU/PICU “Claim to ACA Modifier” Assignment Spreadsheets
Providers may submit/re-submit NICU/PICU “claim to ACA Modifier” assignment spreadsheets. For further explanation and instructions, refer to the Patient Protection and Affordable Care Act: Retroactive NICU/PICU Claim to ACA Modifier Assignment Instructions (PDF).

These spreadsheets must be received no later than June 15, 2015 to be considered for payment.

Providers who believe all payments for their NICU/PICU claims are settled, do not need to do anything further. Providers who have not received NICU/PICU increased payments or have other NICU/PICU claims that qualify, may submit/resubmit the claims on spreadsheets.

If a provider has not received payment, it may be due to the following:

  • The claim previously submitted was received after the deadline.
  • The claim previously submitted was corrupted or had other deficiencies.
  • A claim has not been submitted yet.

To take advantage of this opportunity regarding claims you previously submitted, providers must resubmit those spreadsheets.

The Department of Health Care Services (DHCS) is planning to implement an Erroneous Payment Correction (EPC) in the summer of 2015 to consider additional payment for any claims that may have been missed during the normal ACA payment processes.

June 15, 2015: Online Self Attestation Website will be Decommissioned
Access to enter ACA Primary Care Physician Self Attestation Data will be removed on June 15, 2015, and providers should self-attest before then.

Late Attesters Can Potentially Receive Retroactive ACA Increased Payments
The online attestation site was implemented in July 2013 to allow providers to attest their eligibility for the program. For attestations made prior to November 2013, DHCS issued a one-time retroactive payment to serve as an interim payment representing the estimated ACA payments that might have been expected for all the provider’s previous claims since ACA implementation. Every week thereafter (for most providers), an additional weekly interim payment was made representing the estimated ACA payments that might have been expected for that week’s claims. In addition, periodic retroactive interim payments were also issued to providers who attested after November 2013 and to NICU/PICU providers.

After April 5, 2014, claim-line level payment increases were made prospectively for any provider who successfully attested. Depending upon when a provider attested, they may have retroactive claims that are potentially eligible for the increased ACA payment that have not yet had the increased rate applied. DHCS wants to ensure that all providers get full payment under the ACA on any of their claims which qualify for the increased rates.

As a result, DHCS will issue an Erroneous Payment Correction (EPC) in the summer of 2015 to allow for consideration of retroactive claims for providers who did not attest prior to September 2014, but who did successfully attest thereafter pursuant to DHCS requirements.

True-Up: Recoupment of Excess Interim Payments
In December 2014, DHCS began the true-up process to reconcile actual claim payments for the ACA increases against interim payments advanced to providers from November 2013 through April 5, 2014.

Some providers may have a negative accounts receivable balance due to the amount of money received from ACA interim payments being greater than the dollar value of the actual additional ACA payments to which they were entitled. Providers do not need to take any action as the system is designed to recoup overpayments automatically against future payments.

The excess interim payments occurred for the reasons below:

  • The interim payments were estimated and issued based upon the Medicare rate, but the actual reprocessed claims were paid at a lower amount due to the provider’s usual and customary actual billed amount being less than that allowed by Medicare. DHCS cannot pay more than the amount billed on a claim even if the ACA would have allowed an increased payment had the provider billed a larger amount.
  • ACA payment amounts were less than expected due to differences in claim amounts payable based on geographic pricing. The interim payments were estimated based on a singular Medicare rate instead of actual Medicare rates, which can vary depending on geographic pricing. 

Providers may reconcile their ACA payments and/or interim payment recoupments using the following guidance.

The Remittance Advice Details (RAD) codes below appeared on RAD forms due to the ACA interim payments and subsequent interim payments recoupment:

  • ACA Interim Payments – The Accounts Receivable (AR) Transactions which served to pay providers ACA interim payments were identified with RAD code 1801: Accounts Receivable (AR) – ACA Interim Payment. These interim payments were paid out between November 2013 and April 2014, with additional payout for some providers in September and/or October 2014.
  • ACA Interim Payment Recoupment – The AR Transactions which served to recoup excess interim payments were identified with RAD code 1802: Accounts Receivable – Amount withheld for recoupment of ACA Interim Payment.

Providers who believe that the calculations for their interim payments or amounts recouped are incorrect should write to Xerox Cash Control Unit and follow the directions for sending correspondence to Cash Control.

Providers with other questions can call the Telephone Service Center (TSC) at 1-800-541-5555.