TRICARE Manuals - Display Chap 1 Sect 33 (Baseline, Dec 5, 2022)

General

Chapter 1

Section 33

Bonus Payments In Health Professional Shortage Areas (HPSAs)

Issue Date: April 18, 2003

Revision:

1.0 APPLICABILITY

This policy is mandatory for reimbursement of services provided by either network or non-network providers. However, alternative network reimbursement methodologies are permitted when approved by the Defense Health Agency (DHA) and specifically included in the network provider agreement.

2.0 ISSUE

How are bonus payments in medically underserved areas made?

3.0 POLICY

3.1 Background

3.1.1 On April 15, 2002, the Final Rule was published in the Federal Register (67 FR 18114), allowing for bonus payments, in addition to the amount normally paid under the allowable charge methodology, to providers in medically underserved areas. Medically underserved areas are the same as those determined by the Secretary of Health and Human Services (HHS) for the Medicare program, designated as HPSAs found in all 50 states and Puerto Rico. HPSAs include both primary care and mental health identified HPSAs.

3.1.2 The bonus payments shall be equal to the bonus payments authorized by Medicare, except as necessary to recognize any unique or distinct characteristics or requirements of the TRICARE program, and as described in instructions issued by DHA.

3.1.3 HPSAs include both primary care and mental health identified HPSAs.

3.1.4 The bonus payment applies to both assigned and non-assigned claims. It also applies to network and non-network physicians.

3.1.5 The bonus payment is based on the ZIP code of the location where the service is actually performed, which must be in an HPSA, rather than the ZIP code of the billing office or other location.

3.1.6 The bonus payment is based solely on the amount paid for professional services. Professional services are those that are paid by the professional CHAMPUS Maximum Allowable Charge (CMAC) file, excluding codes that are clinical laboratory services or that are entirely technical in nature. Claims submitted for the technical component only of a service (i.e., have a -TC modifier), if a service can have both professional and technical components, are also ineligible for the HPSA bonus. Thus, all Durable Equipment (DE), injectable drugs, vaccines, facility charges, supplies, etc., are not included in the paid amounts used to calculate the HPSA bonus. The professional service CMAC file’s documentation describes how codes can be detected which are considered entirely technical or clinical lab. Anesthesia services by physicians paid through the anesthesia Relative Value Unit (RVU) and Conversion Factor (CF) files are also to be included as eligible services for the HPSA bonus calculation. Services that are performed by physicians and are professional services (not supplies, drugs, or other such charges) but do not have CMACs may be included in the HPSA bonus calculation, also, such as unlisted or “not elsewhere specified” (e.g., Current Procedural Terminology (CPT) codes 27599, 27899, 30999.

3.1.7 For dates of service prior to January 1, 2018, bonus payments apply under TRICARE Prime, Extra, and Standard for services provided in medically underserved areas. For dates of service on or after January 1, 2018, bonus payments apply under TRICARE Prime and Select for services provided in medically underserved areas.

3.1.8 TRICARE Prime Remote (TPR) and Supplemental Health Care Program (SHCP) shall be included in the bonus payment process.

3.1.9 Under TRICARE For Life (TFL), only those claims where TRICARE is primary would qualify for the bonus payment.

3.1.10 For Other Health Insurance (OHI) claims, the bonus payment would apply, but only on the amount paid by the Government.

3.2 Scope Of Benefit

3.2.1 HPSA

3.2.1.1 The contractor shall make an additional payment quarterly to physicians who qualify and provide services in medically underserved areas (HPSAs).

3.2.1.2 The bonus payment for HPSA, both primary care and mental health areas, is 10% of the amount actually paid, not 10% of the amount allowed, e.g., CMAC. The HPSA bonus payment only applies to physician’s, podiatrist’s, oral surgeon’s, and optometrist’s services rendered in these medically underserved areas. The modifier AQ effective January 1, 2006. As of October 1, 2013, the AQ modifier is no longer required except in those instances where ZIP codes do not fall entirely within a full county HPSA as noted in paragraph 3.2.1.11.

3.2.1.3 The bonus shall be calculated based on 10% of the amount actually paid a physician during a calendar quarter for services rendered in a medically underserved area.

3.2.1.4 Bonus payments are pass-through payments, non-financially underwritten payments.

3.2.1.5 The contractor shall sum all claim payments that qualify for the quarter and pay an additional 10% for the claims. There are no retroactive payments, adjustments or appeals, for obtaining a bonus payment. On or after October 1, 2013, the contractor requirements in paragraphs 3.2.1.11.1, 3.2.1.11.2, and 3.2.1.11.3 shall apply and serve as validation of the HPSA payment.

3.2.1.6 Only professional services are to be included in the calculation of the bonus payment (see paragraph 3.1.6). For example, for services with both a professional and technical component only the professional component is included in the calculation of the bonus payment. The bonus payment is based on where the service is performed, which must be in the medically underserved area not the billing office, or other location (see paragraph 3.1.5).

3.2.1.7 The contractor shall have 30 calendar days from the end of the calendar quarter to make the payments to the providers who qualify.

3.2.1.8 The contractor shall send bonus payments directly to the non-participating physician.

3.2.1.9 When a modifier is required for payment, the modifier must be reported on the TRICARE Encounter Data (TED) record.

3.2.1.10 The contractor shall pay the HPSA bonus by the contractor when provided in ZIP code areas that fall in a county designated as a full-county HPSA. Primary care and mental health HPSA ZIP code files are downloadable from the Medicare website at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/.

3.2.1.11 ZIP codes that do not fall entirely within a full county HPSA.

3.2.1.11.1 Effective October 1, 2013, the AQ modifier shall be entered on the claim in order to receive the bonus when services are provided in ZIP code areas that:

• Do not fall entirely within a designated full county HPSA bonus area; or

• Fall partially within a full county HPSA but are not considered to be in that county based on the United States Postal Service (USPS) dominance decision; or

• Fall partially within a non-full county HPSA; or

• Were included in the automated file of HPSA areas based on the date of the data run used to create the file.

3.2.1.11.2 The contractor shall review the Health Resources and Services Administration (HRSA) website for the most recent designations to determine if the service qualifies to receive the bonus payment (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/) when claims are received with an AQ modifier that do not entirely fall within a full county HPSA.

3.2.1.11.3 The contractor shall verify that the location where the care was provided is included in an HPSA area when a claim includes an AQ modifier.

- END -

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.