Reprocessing of claims for enhanced payments to Primary Care Physicians

Reprocessing of claims for enhanced payments to Primary Care Physicians, subspecialties, physician assistants, nurse practitioners and nurse midwives under the Affordable Care Act.

WEBINAR: March 5, 2014; 12:30pm – 1:30pm (See link below)

The Affordable Care Act (ACA) requires that the Medicaid program pay at the Medicare rate for certain primary care services and to reimburse 100% Medicare Cost Share for services paid in calendar years 2013 and 2014. In September 2013, NCTracks began making the ACA enhanced rate payments to providers who attested and were certified by the state for qualified services billed from that point forward. NCTracks has since been updated to include Health Check, those codes that are billed with an EP modifier, as well as adjustments to the provider Remittance Advice (RA). Now that the changes are complete, retroactive reimbursement for claims submitted from July 1, 2013, through present is starting.

Beginning on Sunday, March 2, 2014, NCTracks started reprocessing of paid physician claims to process enhanced ACA payments. The reprocessing will include physician claims processed and paid in NCTracks from July 1, 2013, through March 1, 2014. The following items will be corrected:

1. ACA enhanced payment for claims with EP modifiers.
2. ACA enhanced payments for providers who have successfully attested through February 21, 2014. You can check your attestation by using the link referred to in item #3.
3. Attestation continues to be ongoing. To attest, please visit the DMA website using the link below.

The claims will be reprocessed as Adjustments and will be reported on the providers Remittance Advice in the March 11th checkwrite. On the paper RAs only, the reprocessed claims will be listed in a separate section titled "SPL PRCS PRACTITIONER PROFESSIONAL ADJT ADJUSTED CLAIMS" and the claims will be reported with a new EOB code of 06040 - "CLAIM REPROCESSED FOR ACA ADJUSTED PAYMENT." Note that in some cases, the reprocessing will not change the reimbursement amount. After Sunday, if you review your claims via the web portal, you will begin seeing the reprocessed claims.

No action is required on the part of certified providers to receive retroactive reimbursement. Reprocessing of Health Choice claims, as well as those claims previously processed by HPES for dates of service between January 1 and June 30, 2013, will be done separately at a later date. Providers will receive notification prior to this reprocessing.

Learn More: DMA will host a webinar on Wednesday, March 5, 2014 from 12:30 – 1:30pm. A web link has been established for this presentation and can be accessed from the link below.