Print

Since June 2003, network and non-network physicians (M.D.’s and D.O.’s) who qualify for Medicare Bonus Payments in Health Professional Shortage Areas (HPSAs) may be eligible
for a 10 percent bonus payment for claims submitted to TRICARE. Moreover, since September 2003, podiatrists, oral surgeons and optometrists also have been able to qualify for bonus payments.

Recently, TRICARE determined that network and non-network primary care physicians who qualify for Medicare Bonus Payments in Physician Scarcity Areas (PSAs) may be eligible for a five percent bonus payment for claims submitted on or after Jan. 1, 2005.

The five percent bonus payment does not apply to podiatrists, oral surgeons or optometrists.  Providers can determine if they are in an HPSA  by accessing the U.S. Department of Health and Human Services, Bureau of Primary Health Care Web site, locating the Data Sources section and clicking on the HPSA Database link. There is also bonus payment information, including HPSA and Physician Scarcity Area designations, on the CMS Web site.

How Bonus Payments Are Calculated

For those providers who are eligible and located in an HPSA, Humana Military’s claims administrator, PGBA, LLC (PGBA), will calculate a quarterly 10 percent bonus payment from the total paid amount for TRICARE claims that contain modifier AQ (HPSA) in Box 24d of the CMS-1500 claim form.

For those providers in a Physician Scarcity Area, PGBA will calculate a quarterly five percent bonus payment from the total paid amount for TRICARE claims that contains the modifier AR (Physician Scarcity Area) in Box 24d of the CMS-1500 claim form.

Bonus payments will be calculated on TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Remote for Active Duty Family Members, TRICARE Extra, TRICARE Standard and TRICARE Reserve Select claims and the amount paid by the government on other health insurance (OHI) claims. There can be only one HPSA and one PSA bonus paid for one service. The provider may receive both bonuses for a total of 15 percent on the same service.

When submitting a TRICARE claim for the bonus payment, providers must include the AQ or AR CPT modifier in Box 24d of the CMS-1500 claim form. For CPT codes with multiple modifiers, place the AQ or AR modifier last. Only the professional component will be used in the calculation of the bonus payment for services that contain both a professional and technical component. Those providers who are eligible and do not submit claims with the appropriate modifier will not receive the bonus payment from TRICARE. There are no retroactive payments, adjustments or appeals for obtaining a bonus payment, so be sure to include the bonus payment modifier with your initial claims submission if you are eligible.

Back to Top     

Got Claims Questions?  Here’s Where You Can Find the Answers (Article 16)