Provider Alerts

Pursuant to the Affordable Care Act (ACA) as amended by the H.R. 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, ACA and 42 Code of Federal Regulations (CFR) 447, state Medicaid agencies are required to reimburse primary care physicians with a specialty designation of family medicine, general internal medicine or pediatric medicine for specified Evaluation and Management (E&M) and Vaccine Administration services.

1. Is there a deadline by which providers must submit the state ACA Self Attestation Form (SAF)?

   Yes, the last day for submission of the SAF is December 31, 2014. It will cover the period from January 1, 2013, through December 31, 2014. However, providers will not be able to receive any payments until their SAF has been completed. If payments for eligible providers are made to a medical group or clinic, the medical group or clinic must sign and submit the HPSJ medical group/clinic attestation form to Health Plan of San Joaquin. The State’s online SAF form is available at http://files.medi-cal.ca.gov/pubsdoco/aca/aca_form_landing.asp. To receive a blank HPSJ Medical Group/Clinic Attestation form, please contact HPSJ’s Provider Services Department at (209) 942-6340.

2. Does a provider need to submit the SAF only once during the time period in which the increased payments are in effect, with the exception of a need to resubmit due to changes or updates to the original submission?

   Yes, the provider needs to submit the SAF only once during the time period in which the increased payments are in effect, unless something changes (e.g. group affiliation).

3. Will the state notify the provider that her/his SAF has been received/approved/denied?

   Yes. Providers are notified of the result via email shortly after the completion of the online SAF. If a confirmation email is not received, please contact the Medi-Cal Telephone Service Center at 1.800.541.5555.

4. Are there any additional items that a provider must do to be eligible for the reimbursement?

   Yes. If a provider receives capitation reimbursement, the provider must submit accurate and timely encounter data to HPSJ, as the data is used to calculate the ACA Supplemental payment.

Providers must submit the state required self-attestation using their Individual NPI, complete the HPSJ medical group/clinic attestation form to HPSJ (if applicable), and submit timely and accurate encounter data if receiving capitated reimbursement before HPSJ can issue any payment.

1. Why have I not received a payment?

   The first payment was made on June 30, 2014 to all providers who met the criteria for payment. Please confirm that you have met the above criteria. If you think you have met the above criteria, and did not receive a payment, please contact HPSJ’s Provider Services Department at (209) 942-6340.

2. I did not meet all of the criteria for the June 30, 2014 payment. If I submit the required information, when can I receive my payment?

   HPSJ is in the process of making the next distribution with an estimated payment date of November 6, 2014. If you did not meet all criteria when the first payment was made, this next payment will include all eligible E&M and Vaccine Administration codes from January 1, 2013 through December 31, 2013.

3. I received the first payment made on June 30, 2014 and have since submitted and been paid for claims/encounter data for the same time period of January 1 – September 30, 2013. Will I receive a supplement for these claims?

   Yes. All ACA payments going forward will pay a supplement on all eligible claims going back to January 1, 2013. However, if claims/encounter data was submitted after the 365 day grace period and were not paid due to missing the submission deadline, a supplemental payment will not be made.

4. I submitted the required encounter data but my payment is still too low or I suspect an error or discrepancy in my payment.

   Please contact HPSJ’s Provider Services Department at (209) 942-6340. We will review and advise you on next steps.

5. Are my payments guaranteed to be at Medicare reimbursement?

   CMS requires Plans to pay up to the Provider Billed Rate or Medicare Rate, whichever is less. You will receive the Medicare equivalent only if you bill at least the Medicare rate for the eligible codes.

6. I don’t understand how the payment was calculated.

   Please refer to the HPSJ Provider Manual (below) for more information on how payments were calculated.

7. I have received a check without RA (Remittance Advice), what do I do?

   If you have not received a RA with your check, you will receive an encrypted CD following the disbursement of the check. If you do not receive the CD within five business days upon receipt of your check, please contact our Provider Services Department at (209) 942-6340.

8. I received a paper RA with my check. How may I obtain an encrypted CD with my RA (Remittance Advice) data?

   Please submit your request to HPSJ’s Provider Services Department at (209) 942-6340.

9. When will ACA payments for 2014 be made?

   You will receive additional ACA payments as HPSJ receives funds from the State and all of the requirements are met. HPSJ will alert you to the distribution schedule once it has been identified.

Details on the Affordable Care Act (ACA) Section 1202 Supplemental Payment, can be found in the Provider Payment Section of HPSJ on-line Provider Manual at hpsj.com.

The Provider Manual can also be accessed through our internet portal Doctor’s Referral Express (DRE).

The ACA 1202 Supplemental Payments provide enhanced reimbursement to help you partner with us to expand access to quality, cost effective health care for our members. If you have any questions, please contact the Provider Services Department at (209) 942-6340.