Claims Processing and Payment (PCIP) program


A. General Overview

Incentive payments will be made on a quarterly basis and shall be equal to 10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) for those services furnished during the incentive payment year. PCIP payments for newly enrolled practitioners will be delayed due to the lag in their eligibility determination. Newly enrolled primary care practitioners will receive a single cumulative PCIP payment, retroactive for primary care services furnished from the beginning of the PCIP payment year, following the fourth quarter of the PCIP payment year after the primary care practitioner is deemed eligible. Quarterly payments will be made for subsequent incentive payments.

On an annual basis Medicare contractors shall receive a Primary Care Incentive Payment Program Eligibility File and PCIP Payment for New Providers Enrolled in Medicare File that they shall post to their websites. The files will list the NPIs of all practitioners who are eligible to receive PCIP payments for the PCIP payment year.

B. Method of Payment

• Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.

• Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.

• Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment, and the HPSA Surgical Incentive
Payment Program (HSIP) payment;

• Provide a special remittance form that is forwarded with the incentive payment so that physicians and practitioners can identify which type of incentive payment (HPSA physician and/or PCIP) was paid for which services.

• Practitioners should contact their contractor with any questions regarding PCIP payments.

C. Changes for Contractor Systems

The Medicare Carrier System, (MCS), Common Working File (CWF) and the National Claims History (NCH) shall be modified to accept a new PCIP indicator on the claim line. Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:

1 = HPSA;

2 = PSA;

3 = HPSA and PSA;

4 = HSIP;

5 = HPSA and HSIP;

6 = PCIP;

7 = HPSA and PCIP; and

Space = Not Applicable.

The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment. The contractor shall also combine the provider’s HPSA physician bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment and/or PCIP payment invoice per provider.
The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per provider.