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HPSA Overview: MMA Section 413(b) requires CMS to revise some of the policies that address HPSA bonus payments. Section 1833(m) of the Social Security Act provides bonus payments for physicians who furnish medical care services in geographic areas that are designated by the HRSA as primary medical care HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act. In addition, for claims with dates of service on or after July 1, 2004, psychiatrists (provider specialty 26) furnishing services in mental health HPSAs are also eligible to receive bonus payments. But keep in mind that if a zip code falls within both a primary care and mental health HPSA, only one bonus will be paid on the service. MMA Changes
Effective January 1, 2005, you no longer have to include a modifier on claims to receive your HPSA bonus payment, which will be paid to you automatically, if you provide care in zip code areas that either: - Fall entirely in a county designated as a full-county HPSA; or
- Fall entirely within the county, through a USPS determination of dominance; or
- Fall entirely within a partial county HPSA.
However, if you provide care in zip code areas that do not fall entirely within a full county HPSA or partial county HPSA, you must enter the AQ modifier on your claim to receive the bonus. The following are the specific instances in which you will need to enter a modifier: - When you provide services in zip code areas that do not fall entirely within a designated full county HPSA bonus area;
- When you provide services in a zip code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision;
- When you provide services in a zip code area that falls partially within a non-full county HPSA;
- When you provide services in a zip code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file.
To determine if you qualify to automatically receive the bonus payment, you can review the information provided on the CMS Web site. The HRSA website should be reviewed for the most recent designations. Physicians may also use the HRSA website designations when making the decision on whether or not to include the HPSA modifier on their claims. Some points to remember include the following: - Medicare carriers will continue to base your bonus on the amount you are actually paid (not the Medicare approved payment amount for each service) and will pay you the ten-percent bonus on a quarterly basis.
- The HPSA bonus pertains only to physician's professional services. Should you bill for a service that has both a professional and technical component, only the professional component will receive the bonus payment.
- The key to eligibility is not that your beneficiary lives in an HPSA nor that your office or primary location is in an HPSA, but rather that you actually render the service in an HPSA.
- A single service may be eligible for both the HPSA bonus payments and the physician scarcity bonus.
- To be considered for the bonus payment, you must include the name, address, and zip code of the location where the service was rendered on all electronic and paper claim submissions.
- Physicians should verify the eligibility of their area for a bonus before submitting
services with a HPSA modifier for areas they think may still require the submission of a modifier to receive the bonus payment. - Services submitted with the AQ modifier will be subject to validation by Medicare.
Do I need to use the "AR" Modifier?
Check the automated pay zip code lists under under Primary Care or Speciality links first. If your zip code is on either list, you do not have to use the "AR" modifier. Do I need to use the "AQ" Modifier?
Areas eligible for payment via the AQ modifier must be verified using your local Carrier Web Sites (See downloads). Provider Center For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) providers, including physicians, other practitioners and suppliers, go to the Provider Center (see under "Related Links Inside CMS" below).
Page Last Modified: 01/21/2009 8:32:49 AM
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