EmblemHealth Qualified Provider Reimbursement Methodology Primary Care Reimbursement Incentive

Date Issued: 10/16/2013

The Affordable Care Act stipulates eligible* primary care providers will be reimbursed at Medicare rates for Evaluation and Management codes (99201-99499) and Vaccine Administration codes (90460, 90461, 90471, 90472 and 90474) for services rendered to EmblemHealth Medicaid managed care and Family Health Plus (FHPlus) members.

Fee-for-Service Providers
There is no plan to update our current fee schedules. We will reimburse all eligible providers the difference between the 2013/2014 Medicare rates and the provider paid amount for all eligible procedure codes. Provider reimbursement will be calculated and reconciled on a quarterly basis.

Capitated Providers
The Medicaid payment rate for each eligible capitated encounter will be determined based on the submitted priced encounter or, in the absence of this information, what we would have paid the provider if the encounter was paid on a non-capitated, fee-for-service basis. We will then reimburse all eligible providers the difference between the 2013/2014 Medicare rates and the provider paid or determined amount for all eligible procedure codes. Provider reimbursement will be calculated and reconciled on a quarterly basis.

To ensure that all payments arrive in a timely manner, please contact us anytime there is a change in your practice information, such as your address, network participation status, or adding or closing a location.

*Every month the state makes available a list of the practitioners and their locations that qualify for this additional reimbursement.