At Independence, we are committed to our members's care. Most medically
necessary and preventive services provided to our commercial and Medicare
Advantage HMO and POS members 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 the following Independence policies:
- Commercial: #00.10.01y: Services Paid Above Capitation for
Health Maintenance Organization (HMO) and Health Maintenance Organization
Point-of-Service (HMO-POS) Primary Care Providers
- Medicare Advantage: #MA00.033e: 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 policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy
Online, and select Commercial or Medicare
Advantage from the top of the page and type the policy name or number
in the Search field.