Background

Section 1833(m) of the Social Security Act (the Act) provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332(a)(1)(A) of the Public Health Services (PHS) Act. This section of the PHS Act pertains to geographic-based HPSAs. Therefore, the Medicare incentive payments are available only in geographic HPSAs.

Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5 percent incentive payment. Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10-percent incentive payment.

Eligibility

Eligibility for receiving the 10 percent bonus payment is based on where the service is rendered. Zip code 11451 and other census tract numbers are HPSA designations in Queens County. Services performed outside a HPSA designated area do not qualify for the incentive payment and is a violation of this provision.

Only physicians furnishing services in a primary care HPSA are eligible to receive incentive payments. In addition, effective for claims with dates of service on or after July 1, 2004, psychiatrists furnishing services in mental health HPSAs are eligible to receive incentive payments. There are currently no eligible mental health HPSAs in Queens County.

CMS does not recognize dental HPSAs for the incentive payment program since Medicare does not cover dental services for Medicare beneficiaries.

How to bill in order to receive a HPSA bonus payment

Prior to January 1, 2006, physicians show that their services were rendered in an incentive-eligible HPSA by including modifier QU/QB (physician providing service in an urban/rural HPSA) to the service on the CMS-1500 claim form. These modifiers are no longer valid effective January 1, 2006.

Please check the CMS web site at www.cms.hhs.gov/providers/bonuspayment to determine whether the HPSA bonus payment will be automatically paid for services rendered in your area. In Queens County, zip code 11451 is the only zip code on the automated list. If you provided Primary Care services in zip code 11451, you do not need to use a modifier to receive the HPSA bonus payment.

If the zip code of the location where you render services is not on the automated list, you need to determine if this location is within a HPSA bonus area. See below for a list of eligible HPSA areas in Queens County. Effective January 1, 2006, if your zip code is not on the automated payment list, you must use the “AQ” modifier to claim the HPSA bonus payment.

How HPSA bonus payments are received

The incentive payment is 10 percent of the amount actually paid, not the approved amount. These payments are made on either assigned or unassigned claims. HPSA bonus payments are issued at the end of each quarter.

A quarterly incentive report is generated for each physician who received payments for services rendered in a HPSA designated area.

Physicians may request a review within 120 days from the date of the initial determination if they feel that the amount is incorrect. The physician has 12 months from the initial claim determination to request a reopening.

Provider Responsibility

It is the provider’s responsibility for assuring that they and their billing staff are aware of correct claim filing and must use care when billing and accepting payment from Medicare.

HPSA Designations in Queens County

Designations on this list that are not in zip code 11451 will require use of the “AQ” modifier to claim the HPSA bonus payment.