Policy Updates Reimbursement PoliciesMedicaidNovember 15, 2024

Targeted rate increase: update

On June 20, 2024, the Department of Health Care Services (DHCS) published Targeted Rate Increases (TRI) APL 24-007 for professional primary care, obstetric care, and nonspecialty mental health services retroactive to January 1, 2024. We are now reimbursing eligible claims submitted by in-scope providers at the new TRI Fee Schedule rate. With this change, we are no longer administering Proposition 56 Physician Services payments for dates of service on or after January 1, 2024.

Professional services defined as the financial risk of the primary medical group (PMG)/independent physician association (IPA) must also adhere to the requirements outlined in APL 24-007 and reimburse network providers at no less than the TRI Fee Schedule rate for clean claims received after December 31, 2024, for dates of service on or after January 1, 2024. We have engaged each of the PMG/IPA organizations to work towards full compliance with the requirements outlined in APL 24‑007.

List of provider types defined by DHCS as eligible for TRI (based on primary taxonomy code):

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Podiatrists
  • Certified nurse midwives
  • Licensed midwives
  • Doula providers
  • Psychologists
  • Licensed professional clinical counselor
  • Licensed clinical social workers
  • Marriage and family therapists

PMG/IPA must pay all claims for dates of service from January 1 to December 31, 2024, for in-scope services at the TRI Fee Schedule rate by December 31, 2024, in addition to paying a clean claim received after December 31, 2024, at the TRI Fee Schedule rate.

Federally qualified health centers (FQHCs), rural health clinics (RHCs), and American Indian Health Service Programs, as well as cost-based reimbursement clinics, are not eligible for TRI Fee Schedule rates.

The current payment methodology allows Anthem to reimburse the supervising physician for services rendered by a nurse practitioner or physician assistant. As outlined in APL 24-007, it is a requirement for qualifying services rendered by a nurse practitioner or physician assistant to be reimbursed at no less than the TRI Fee Schedule rate. It is the responsibility of the supervising physician who holds a contractual agreement with the nurse practitioner or physician assistant to ensure that the rendering provider is receiving reimbursement for services at no less than the TRI Fee Schedule rate.

Prop 56 Physician Services update

All procedure codes included in the Proposition 56 Physician Services program (APL 23-019) are found on the TRI Fee Schedule effective January 1, 2024. The TRI Fee Schedule rates are defined by DHCS as being inclusive of the Proposition 56 Physician Services directed payment amount and the Prop56 Physician Services program under APL 23-019 is effectively terminated as of December 31, 2023.

Historical claims adjustment: dates of service on/after January 1, 2024

Claims received by Anthem are being adjusted to pay at no less than the TRI Fee Schedule rate. The adjustment of an eligible claim may result in an additional check and remittance advice (RA) reflecting the new payment.

Reference the sample RA below, including the retraction of Prop56 Physician Services supplemental payment and the issuance of the new TRI Fee Schedule rate.

Sample remittance

First record: retraction of previously paid amount

In the example above, procedure code 99392 previously paid $37.39 with a Prop56 supplemental payment amount of $79, for a total of $116.39, which has been retracted.

Second record — issuance of the new TRI Fee Schedule rate

The TRI Fee Schedule rate for 99392 is defined by DHCS as the Medi-Cal Base Rate plus the Prop56 Physician Services supplemental payment amount ($37.39 + $79 = $116.39). Therefore, there is no net positive adjustment to the payment on this sample claim.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

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