UPDATE: Proposition 56 Supplemental Payment for Physician Services
| Date: | May 3, 2018 |
| To: | Health Plan of San Joaquin (HPSJ) PCPs and Specialists |
| From: | HPSJ Claims Department |
| Subject: | UPDATE: Proposition 56 Supplemental Payment for Physician Services |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) received the Centers for Medicare & Medicaid Services (CMS) approval of the State Plan Amendment (SPA) 17-030. SPA 17-030 authorizes a one year (from July 1, 2017 through June 30, 2018) supplemental payment for certain physician services, funded by the California Healthcare, Research and Prevention Tobacco Act of 2016 (Proposition 56) and matching federal funds.
Supplemental payments for the impacted services will be made based on claim submissions for specific Current Procedural Terminology – 4th Edition (CPT-4) codes as follows:
| CPT-4 Codes | Supplemental Payment |
| 90863 | $5.00 |
| 99201, 99211 | $10.00 |
| 99202, 99212, 99213 | $15.00 |
| 99203, 99204, 99214, 99215 | $25.00 |
| 90791, 90792 | $35.00 |
| 99205 | $50.00 |
No action is required of providers.
HPSJ will begin initiating retroactive supplemental payments on claims with a date of service July 1, 2017 forward that have been received and previously processed through check date 05/04/2018. This retroactive payment will be made to qualified providers in a lump sum. Documentation will be provided with the payment for the affected claims.
Any claim processed on 05/02/2018 and forwarded for claims with a date of service of July 1, 2017 through June 30, 2018, will include the supplemental payment through the normal claims processing and will be included in the claims payment on the provider’s weekly checks. If you feel that a claim met Proposition 56 criteria and was not included in the direct payment, please file a Dispute online through the DRE portal or by mail. Providers may refer to the Proposition 56 Supplemental Payment Methodologies PDF or APL 17- 030 on the DHCS website or for more information regarding Proposition payments for physician services.
If you need additional information, please contact our Customer Services Department at 209-942-6320.