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Last Modified: 9/15/2021 Location: FL, PR, USVI Business: Part B

Reprocessing claims under the Primary Care First (PCF) model

Issue

CMS has identified a claims processing issue that potentially impacts all Cohort 1 Primary Care First (PCF) participants that submitted claims for flat visit fee (FVF) eligible services processed between January 1, 2021, and February 3, 2021. During this time, FVF eligible services provided by PCF practices to their attributed beneficiaries were not accurately identified, and as a result were reimbursed under traditional Medicare fee-for-service (FFS) rules rather than the intended PCF payment structure.
Similarly, certain claims for chronic care management (CCM)-related and evaluation and management (E/M) add-on services provided by PCF practices to their attributed beneficiaries processed between January 1, 2021, and April 5, 2021, were not properly denied according to PCF payment rules. As a result, these claims were erroneously processed under traditional FFS payment and beneficiary cost-sharing rules. PCF practices are already reimbursed for these services via a non-claims-based payment through the Professional Population-Based Payment (PBP). Therefore, under PCF payment methodology, CMS intends to deny these claims and eliminate any beneficiary cost-sharing for these services.

Resolution

CMS and MACs are working closely to reprocess these claims to accurately reflect the PCF payment methodology. Claims reprocessing will begin in October 2021 and may continue through the end of the calendar year. As the MACs reprocess claims, PCF practices may receive multiple letters requesting the difference in Medicare payments between the erroneously paid FFS amount and the corrected PCF amount. For some FVF services, practices may receive additional payments from Medicare if the FFS amount paid is below the FVF rate.

Status/date resolved

Open

Provider Action

None

Current processing issues

Here is a link to a table of current processing issues for both Part A and Part B.
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