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Reimbursement for Professional Services

Minnesota Health Care Programs Enhanced Payment Rates for Certain Primary Care and Vaccine Administration Services

As required by the Affordable Care Act (ACA), Medicare rates are to be paid to eligible practitioners for Minnesota Health Care Programs (MHCP) claims for certain primary care and vaccine administration services with dates of service in 2013 and 2014.

In accordance with procedures established by the Minnesota Department of Human Services (DHS) and the Centers for Medicare & Medicaid Services (CMS), the enhanced rates for MHCP enrollees covered by Managed Care Organizations (MCOs) will be calculated retrospectively by DHS and distributed to eligible health care providers by the MCOs in several lump sum payments. MCOs are required to make the lump sum payments within 30 days of receipt of funds from DHS. The lump sum payments are anticipated to be grouped as follows:

 First Payment Eligible claims processed by MCOs in calendar year 2013 
Second Payment  Eligible claims processed by MCOs in the first and second quarters of 2014 
Third Payment  Eligible claims processed by MCOs in the third quarter of 2014 
 Fourth Payment Eligible claims processed by MCOs in the fourth quarter of 2014 
 Subsequent Quarterly Payments Eligible run-out claims processed by MCOs during the calendar quarter 

Medica will pay the enhanced amounts in lump sum checks written to the legal entity which employed the eligible primary care practitioners at the time of the date of services, accompanied by a report indicating the total amount to be paid to each primary care practitioner. The provider must then pass along these amounts to the individual practitioners. In the event that the practitioner is no longer employed by the provider receiving the check, the provider must make good faith efforts to pass along such amounts to such practitioner, and if that is not possible, return such amounts to Medica with the explanation that the provider was unable to forward the payment to the specific named primary care practitioner.

Please note that this is a contractual requirement under Medica's contract with DHS, and records of the provider's compliance with this requirement to forward these amounts to the named primary care practitioners will be included in Medica's audits of providers.

Date: 9/16/2019 7:54:22 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB02