California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.12.6 - Geographic Health Professional Shortage Area Bonus Payment: Primary Care; Mental Health

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Physicians who provide professional services in a Geographic Health
					 Professional Shortage Area (HPSA) are eligible for a 10-percent bonus payment.
					 Eligibility for receiving the 10 percent bonus payment is based on whether the
					 specific location at which the service is furnished is within an area that is
					 designated as a Geographic HPSA by the Health Resources and Services
					 Administration (HRSA), within the United States Department of Health &
					 Human Services.
Physicians, including psychiatrists, furnishing services
						in a primary medical care Geographic HPSA are eligible to receive bonus
						payments. In addition, psychiatrists furnishing services in mental health
						Geographic HPSAs are eligible to receive bonus payments.
It is not enough for the physician merely to have his/her
						office or primary service location in a Geographic HPSA, nor must the injured
						worker reside in a Geographic HPSA. Eligibility for the bonus is determined by
						where the service is actually provided (place of service). For example, a
						physician providing a service in his/her office, the patient's home, or in a
						hospital qualifies for the incentive payment as long as the specific location
						of the service is within an area designated as a Geographic HPSA. On the other
						hand, a physician may have an office in a Geographic HPSA but go outside the
						office (and the designated Geographic HPSA area) to provide the service. In
						this case, the physician would not be eligible for the incentive
						payment.
(b) Only services
					 provided in areas that are designated as of December 31 of the prior year are
					 eligible for the Geographic HPSA bonus payment. Physicians providing services
					 in areas that were designated as of December 31 of the prior year but not on
					 the automated file shall use the AQ modifier. Only services provided in areas
					 that were designated as of December 31 of the prior year but not on the
					 automated file may use the modifier. Services provided in areas that are
					 designated during the year will not be eligible for the Geographic HPSA bonus
					 payment until the following year, provided they are still designated on
					 December 31. Services provided in areas that are de-designated during the year
					 will continue to be eligible for the Geographic HPSA bonus through the end of
					 the calendar year.
(c) The claims
					 administrator shall automatically pay bonuses for services rendered in ZIP Code
					 areas that fully fall within a designated primary care or mental health full
					 county Geographic HPSA; are considered to fully fall in the county based on a
					 determination of dominance made by the United States Postal Service (USPS); or
					 are fully within a partial county Geographic HPSA area.
(d) Should a ZIP Code fall within both a
					 primary care and mental health Geographic HPSA, only one bonus will be paid on
					 the service. Bonuses for mental health Geographic HPSAs will only be paid when
					 performed by the provider specialty of 26 -- psychiatry.
(e) For services rendered in ZIP Code areas
					 that do not fall within a designated full county Geographic HPSA; are not
					 considered to fall within the county based on a determination of dominance made
					 by the USPS; or are partially within a partial county Geographic HPSA,
					 physicians must submit an AQ modifier to receive payment.
To determine whether a modifier is needed, physicians
						must review the information provided on the CMS web site or the HRSA web site
						for Geographic HPSA designations to determine if the location where they render
						services is within a Geographic HPSA bonus area. Physicians may also base the
						determinations on letters of designations received from HRSA. They must be
						prepared to provide these letters as documentation upon the request of the
						claims administrator.
For services rendered in ZIP Code areas that cannot
						automatically receive the bonus, it will be necessary to know the census tract
						of the area to determine if a bonus should be paid and a modifier submitted.
						Census tract data can be retrieved by visiting the U.S. Census Bureau Web site
						at
http://www.census.gov/
or the
						Federal Financial Institutions Examination Council (FFIEC) Web site at
http://www.ffiec.gov/geocode/
.
						Instructions on how to use these Web sites can be found on the CMS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HPSAPSAPhysicianBonuses/index.html?redirect=/hpsapsaphysicianbonuses/
.
(f) The claims administrator shall pay the
					 10% bonus together with the payment for the service performed in the Geographic
					 HPSA designated area. The Geographic HPSA bonus pertains only to physician's
					 professional services. Should a service be billed that has both a professional
					 and technical component, only the professional component will receive the bonus
					 payment.
(g) See section
					 9789.19, by date of service, for:
(1) The links for the Primary Care HPSA zip
					 code file and the Mental Health HPSA zip code file listing zip codes that will
					 automatically receive the Geographic HPSA bonus;
(2) The HRSA web link to determine if a
					 particular address is in a Primary Care Geographic HPSA and/or a Mental Health
					 Geographic HPSA;
(3) The HRSA web
					 link to find Primary Care Geographic HPSA and Mental Health Geographic HPSA by
					 State & County.