Primary care sub-capitation program

We employ a nurse practitioner or physician assistant who works in a specialty clinic, but they bill using the same TIN as some of our PCPs. Does this mean some of their claims will be zero paid?

Yes, according to the MassHealth logic, those providers’ claims for included codes will be zero paid if they are seeing a member who is attributed to a PCP who bills under the same TIN.

What happens if we have a cardiologist who is dually boarded in internal medicine? Does that mean all of their claims will be zero paid under the cap?

This provider’s claims for included codes would be zero paid if they are seeing members who are attributed to a PCP who bills under the same TIN. If the provider bills under a different TIN, then their claims will be paid fee for service.

My clinic employs a provider who is dually boarded in family medicine and psychiatry and carries a panel. Will their claims be zero paid under the cap?

Usually no. This provider’s claims will usually be paid fee for service because they are excluded under the MassHealth specialty logic criteria. The exception is if your clinic is a non-hospital-licensed FQHC, in which case all claims for your attributed members will be zero paid regardless of provider specialty.

My clinic employs an endocrinologist who is only boarded in endocrinology, not internal medicine, but serves as a PCP for certain patients. Will their claims be zero paid under the cap?

Usually no. This provider’s claims will usually be paid fee for service because they are excluded under MassHealth specialty logic criteria. The exception is if your clinic is a non-hospital-licensed FQHC, in which case all claims for your attributed members will be zero paid regardless of provider specialty.

We are a federally qualified health center (FQHC) that employs specialists. What will happen to their claims?

The answer depends on whether your FQHC is hospital licensed or not. If your FQHIC is hospital licensed, claims will zero pay (or not) according to MassHealth’s standard specialty logic, which takes into account the specialties of the providers rendering the service.

If your FQHC is not hospital licensed, all of your claims for included codes will zero pay for members attributed to your health center regardless of the provider’s specialty.

I am a PCP who is going to bill a code that is not on the MassHealth included code list, but is also not on the excluded list. Will this code zero pay?

No. WellSense will only zero pay codes that appear on the MassHealth included code list.

My clinic drops both facility and professional claims for primary care visits. Would both claim types be zero paid under this program?

The answer depends on the TIN used for billing each claim. If your group uses the same TIN for both facility and professional claims, then both will be zero paid under the sub-cap program if the member is attributed to that TIN. If your group uses a separate TIN for facility claims, they will be excluded from sub-cap and paid fee-for-service during the first year of the program.

How do I know if a claim zero paid because of PC sub-cap?

The code will have an explanation code of “CAP” on paper remits or CARC 24 (“Charges are covered under a capitation agreement/managed care plan”) on electronic remits.

My group has several locations, and each location has several PCPs. If a member is assigned to location A but goes to location B, will their claims be zero paid?

The answer depends on the TIN each location uses for billing. If the providers at both locations use the same TIN, then the claims will be zero paid. If the providers at each location use different TINs, then the claims will be paid fee for service.

What happens if my clinic sees a patient for primary care who is not attributed to our group?

If that patient is a member of your same ACO but is not attributed to a group that bills under the same TIN as your group, the claim will pay fee-for-service.

How does WellSense calculate monthly cap payments?

WellSense follows MassHealth guidance for calculating monthly cap payments. To do so, we multiply the number of members attributed to a TIN on the first day of each month in each rating category by the rate that MassHealth calculated for your group’s TIN + rating category combination. If a member was eligible for only part of a month, they will receive a prorated payment based on the percentage of the month they were eligible.

Does WellSense use the MassHealth specialty logic to determine which PCPs get monthly cap payments?

No, WellSense only uses the MassHealth specialty logic to determine which claims to zero pay. WellSense looks at which providers have members attributed to them in our system in order to calculate monthly cap payments. A provider will only have members attributed to them if your group has indicated to us that the provider is a PCP with an open panel on your provider enrollment forms. You can always update provider information with us by using our Provider Change and Termination form.

What happens if one of my providers practices at more than one group? Can they get more than one payment?

WellSense creates a unique provider record for each national provider identifier (NPI) and TIN combination. This means that if the provider practices at two different locations that bill under two different TINs, the provider can carry separate panels. However, if the two locations use the same TIN for billing, the provider can only carry a panel at one of those locations. In this case, if the provider sees a member attributed to their primary location at another location, that claim would still be zero paid.

For the purposes of PC cap, we are attributing the provider to the address that your group has indicated is their primary practice location. If you would like to update their primary location, you can submit a Provider Change and Termination form at any time.

Will we get more tier dollars if we assign new members to one of our locations with a higher tier?

Not at first. MassHealth has integrated tier payments into the rates they have set for each TIN. They have reserved the right to recalculate those tier payment midyear, but at least for the first few months of the program, the distribution of your members across your tiers will not affect your per-member rates.

What happens to my monthly payments if a member becomes retroactively eligible (or ineligible) for MassHealth?

WellSense will use a three-month lookback period to adjust monthly payments for retroactivity. This means that if a member becomes retroactively eligible, you will see a positive adjustment in your next month’s payment. If they are retroactively ineligible, you will see a negative adjustment.

What happens to my monthly payment if a member joins MassHealth mid-month and gets attributed to my group?

WellSense is using a three-month lookback period for adjustments. At the beginning of the month following the member’s arrival or departure, our system will automatically include the new member. At that time, WellSense will calculate the appropriate fractional payment for the prior month and account for this as a positive adjustment. The same logic will apply if a member is disenrolled midmonth. You will see a negative adjustment in the next month’s payment.

What happens if an existing MassHealth member switches PCPs and joins my group mid-month?

You will receive the full monthly payment for the member starting the next month. WellSense uses the member’s attribution as of the first day of the month to allocate the full month’s payment. WellSense is not calculating fractional payments if a member switches groups mid-month.

I have a question about my monthly cap payment. Whom should I contact?

Please contact your assigned Provider Relations Consultant with questions related to PC sub-cap monthly cap payments.