Bonus Payments in Health Professional Shortage Areas
Network and non-network physicians (doctors of medicine [MDs] and doctors of osteopathic medicine [DOs]), podiatrists, oral surgeons, and optometrists 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. The only behavioral health care providers who are eligible for HPSA bonuses are MDs and DOs. Non-physicians (PhDs, social workers, counselors, psychiatric nurse practitioners, and marriage therapists) are not eligible.
Providers can determine if they are in an HPSA\ by accessing the U.S. Department of Health and Human Services, Health Resources and Services Administration’s HPSA search tool. The Centers for Medicare and Medicaid Services (CMS) has HPSA designations along with bonus payment information at the HPSA/PSA Overview web page.
How Bonus Payments are Calculated
For providers who are eligible and located in an HPSA, Humana Military’s claims processor, PGBA, will calculate a quarterly 10 percent bonus payment from the total paid amount TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Remote for Active Duty Family Members, TRICARE Standard and TRICARE Extra, TRICARE Reserve Select, and TRICARE Retired Reserve claims, and the amount paid by the government on other health insurance claims.
Please keep in mind the following:
- When submitting a claim for the bonus payment, providers must include the AQ CPT modifier in Box 24D of the CMS-1500 claim form.
- For CPT codes with multiple modifiers, place the AQ modifier last.
- If you are eligible for a bonus payment but do not submit claims with the appropriate modifier, you will not receive the bonus payment from TRICARE. There are no retroactive payments, adjustments, or appeals for obtaining a bonus payment, so include the bonus payment modifier with your initial claims submission if you are eligible.
- When calculating bonus payment for services that contain both a professional and technical component, only the professional component will be used.
Note: Although Medicare no longer requires the use of modifiers, TRICARE still requires their use. If you submit claims without the modifier, you cannot receive a bonus payment. |
