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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule
§9789.12.6. Health Professional Shortage Area Bonus Payment: Primary Care; Mental Health.
(a) Physicians who provide professional services in a 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 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 HPSA are eligible to receive bonus payments. In addition, psychiatrists furnishing services in mental health 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 HPSA, nor must the injured worker reside in a 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 HPSA. On the other hand, a physician may have an office in a HPSA but go outside the office (and the designated 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 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 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 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 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 HPSA area.
(d) Should a ZIP Code fall within both a primary care and mental health HPSA, only one bonus will be paid on the service. Bonuses for mental health 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 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 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 HPSA designations to determine if the location where they render services is within a 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 HPSA designated area. The 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 HPSA bonus;
(2) The HRSA web link to determine if a particular address is in a Primary Care HPSA and/or a Mental Health HPSA;
(3) The HRSA web link to find Primary Care HPSA and Mental Health HPSA by State & County.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
2. Amendment of subsection (e) filed 3-23-2016; operative 1-1-2016 pursuant to Labor Code section 5307.1(g)(2). Submitted to OAL for filing and printing only pursuant to Labor Code section 5307.1(g)(2) (Register 2016, No. 13).