At AmeriHealth, we are committed to our members care. Most medically necessary and preventive services provided by a primary care physician (PCP) are included in the monthly capitation payment. However, some services that can be performed at a PCP's office (e.g., wart removal or vaccines) are eligible to be paid above the monthly capitation rate.

A complete list of services that are paid over and above the monthly capitation payments (above capitation) is available in Attachments A, B, and C (depending on PCP's state) in Medical Policy #00.10.01y: Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers.

PCPs are also eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules. 

If you opt to perform these services in your office, be sure to submit the required documentation as noted in the policy.

By using these fee-for-service reimbursements, we can help our members by reducing the need for referrals or specialist visits.

For more information

To view the above policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online from the top of the page, select the Commercial tab, and type the policy name or number in the Search field.