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Reprocessing claims under the Primary Care First (PCF) model
Last Modified: 9/15/2021
Location: FL, PR, USVI
Business: Part B
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.
CMS is working closely with MACs to reprocess affected 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 to reflect the correct financial adjustments under PCF model rules, practices will receive letters detailing the amount of money either owed to Medicare by practices or by Medicare to practices. CMS apologizes in advance for this reprocessing as we know it puts a large burden on practices’ billing departments. For further questions or concerns, please contact your local MAC.
What is the flat visit fee?
One component of the PCF payment structure is the FVF, which supports practices delivering primary care face-to-face. The FVF is a flat Medicare payment currently set at $40.82 (prior to geographic adjustment) for face-to-face primary care patient encounters between PCF practices and their attributed beneficiaries. The FVF applies when practices bill eligible primary care HCPCS codes for an attributed beneficiary. Medicare only pays one FVF per beneficiary, per date of service. The FVF payment only applies to the Medicare portion of claim payment. CMS applies beneficiary cost-sharing to all services submitted on the claim under standard FFS rules and rates.
What services are included in the flat visit fee?
HCPCS codes for FVF eligible services:
• Office/outpatient E/M: 99202–99205, 99211–99215
• Prolonged E/M: 99354, 99355, 99415, 99416
• Transitional care management services: 99495, 99496
• Home care/domiciliary care E/M: 99324–99328, 99334–99337, 99341–99345, 99347–99350
• Advance care planning: 99497, 99498
• “Welcome to Medicare” and Annual Wellness Visits: G0402, G0438, G0439
What services are included in the list of prohibited HCPCS codes?
PCF providers are prohibited from billing CCM-related services (99339, 99340, 99439, 99487, 99489, 99490, 99491) as well as E/M add-on code (G2212) for any PCF beneficiaries, as they are already reimbursed through the Professional PBP.
How do I know if my practice was affected?
If your practice submitted any claims for FVF eligible services or prohibited CCM-related services and E/M add-on codes for your PCF attributed beneficiaries between January 1, 2021 and February 3, 2021 it may have been affected. Additionally, if you submitted a claim for the HCPCS codes G2212 or 99439 on or before April 5, 2021, it may have been affected. Claims that were processed during this time frame were not accurately flagged as PCF claims and therefore were not accurately processed in accordance with the PCF payment methodology. If a service was provided during this time frame but the claim was submitted and processed by your MAC after this time frame, then the payment should accurately reflect the correct PCF payment amount.
How many claims were impacted?
The number of claims impacted depends on the number of 1) FVF eligible and 2) prohibited CCM-related services and E/M add-on codes your practice provided to your attributed beneficiaries during the affected period. For a complete count of affected claims, you may contact the PCF Help Desk at
PCF@Telligen.com 
or 888-517-7753, and they will be able to provide a number.
What is CMS doing to fix this?
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.
Is this still an ongoing issue?
No, this is not an ongoing issue. After February 3, 2021, claims for FVF eligible services and prohibited services (except for HCPCS G2212 and 99439) were processed correctly. After April 5, 2021, claims for HCPCS G2212 and 99439 were processed correctly.
Why is CMS adjusting my FFS payments?
Between January 1, 2021 and February 3, 2021, claims for FVF eligible services were not accurately identified and processed using the PCF FVF methodology. These claims were inaccurately processed and reimbursed at the Medicare FFS rate, resulting in incorrect payments to PCF practices. Additionally, between January 1, 2021 and April 5, 2021, certain claims for PCF prohibited CCM-related services and E/M add-on codes were erroneously reimbursed when they should have been denied.
A PCF participating practice agrees to join the model and be paid under the PCF payment structure. Therefore, in accordance with the participation agreement practices sign upon entering the model, all payments to practices must be made using PCF methodology. CMS is correcting an error from earlier this year in which claims were incorrectly paid to PCF practices. Thus, CMS needs to make the necessary financial reconciliations to stay in accordance with PCF participation guidelines.
How does this impact cost-sharing for my beneficiaries?
For reprocessed FVF claims, beneficiary cost-sharing is unaffected. CMS calculates the patient deductible and coinsurance based on the Medicare Physician Fee Schedule (MPFS) allowed amount for the submitted claim under traditional FFS, rather than the adjusted FVF amount. Thus, the deductible and coinsurance are equivalent to what a beneficiary would pay under traditional FFS for the same primary care service. In other words, the beneficiary is unaffected by their attribution to the PCF component in terms of their deductible and coinsurance.
Claims for prohibited CCM-related services and E/M add-on codes that were erroneously paid between January 1, 2021, and April 5, 2021, will be reprocessed and denied with no beneficiary liability. Thus, your MAC will request that your practice credit the cost-sharing payer. Since practices are already reimbursed through the Professional PBP for these services, under PCF payment rules, CMS will deny claims for these services when provided to their attributed beneficiaries.
How does this impact cost-sharing by a secondary insurer?
For reprocessed FVF claims, secondary insurance coverage is unaffected. Secondary insurers pay cost-sharing for FVF services based on the MPFS allowed amount for the submitted claim under traditional FFS rather than the adjusted FVF amount.
Reprocessed claims for prohibited CCM-related services and E/M add-on codes erroneously paid between January 1, 2021, and April 5, 2021, may involve secondary insurers. When these claims are reprocessed, they will be denied with no beneficiary liability and practices should credit the cost-sharing payer. In cases where a beneficiary’s secondary insurer was the cost-sharing payer, the secondary payer may decide to reprocess the affected claims to recoup any cost-sharing payments made for these PCF prohibited services. Please note that secondary insurers are not required to reprocess claims and may do so on a voluntary basis.
Coordination of Benefits Agreement (COBA) trading partners that exclude adjustment claims (including adjustment claims/monetary and mass adjustment claims/other), as well as 100% denied adjustment claims, with no beneficiary liability, will not receive the “corrected” claims via the COBA Medicare crossover process.
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