Health Professional Shortage Areas (HPSA)
In accordance with Section 1833(m) of the Social Security Act, physicians who provide covered professional services in a geographic HPSA are entitled to a 10-percent incentive payment. The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating Health Professional Shortage Areas.
The address where the service is rendered, not the location of the physician's office or the patient's address, is the determining factor in HPSA incentives.
Only physicians furnishing services in a geographic, primary care HPSA are eligible to receive bonus payments. Eligible providers include medical doctors, psychiatrists, doctors of osteopathy, dentists, doctors of podiatric medicine, licensed chiropractors, and optometrists. Non-physician practitioners, such as physician assistants and nurse practitioners, are not eligible for the bonus payment.
In addition, psychiatrists, specialty 26, furnishing services in geographic, mental health HPSAs are eligible to receive bonus payments. However, should an area be both a mental health HPSA and a primary care HPSA, only one ten-percent incentive payment will apply to a single service.
The incentive payment is issued quarterly. It is 10 percent of the amount actually paid by Medicare, not the approved amount, for professional services performed in a geographic HPSA. It is not necessary for the physician to be a participating provider, or for the claim to have been assigned.
Important: If you qualify for HPSA bonus payments, you will fall into one of two groups; those who must indicate that a service was rendered in a geographic HPSA when submitting claims using the appropriate modifier, and those who are on the automated zip code file. If the zip code of the facility where the services were rendered is on the automated zip code file, the bonus will automatically be posted to the claim, and then at the end of the quarter, you will receive a bonus payment. For those in the former group, you must indicate that a service was rendered in a geographic HPSA, by using the AQ modifier. The AQ modifier indicates that the physician is providing services in a HPSA.
You can check the following web sites to see if you are eligible for the HPSA bonus payment:
- Verify Automated HPSA Bonus Designation Status on the CMS Website
Scroll down the page to the Downloads section and select the HPSA file for the appropriate year. - Verify HPSA Status on the Health Resources and Services Administration (HRSA) Website You can click on the HPSA Eligible for the Medicare Physician Bonus Payment link to enter an address to check it's HPSA eligibility
Effective for claims with dates of service on or after January 1, 2009, only services furnished in areas that are designated as geographic HPSAs as of December 31 of the prior year are eligible for the HPSA bonus payment. Services furnished in areas that are designated at any time during the current year will not be eligible for the HPSA bonus payment until the following year, provided they are still designated on December 31.
In order to be considered for the bonus payment, the name, address, and zip code of where the service was rendered must be included on all electronic and paper claims submissions. This information should be entered in ANSI 4010A1 Loop 2310D 2-250-NM103 (FA, TL, 77, LI) for the electronic HIPAA 4010A1 format, or in Item 32 of the CMS 1500 claim form.
On a post-payment basis, Medicare will monitor claims submitted with the AQ modifier to verify eligibility for the bonus payment. Incorrect use of the HPSA modifiers can result in a violation of Medicare law.
Physicians can choose not to receive any HPSA bonus payment on services that would otherwise be eligible. Please contact us if you choose not to receive any bonus payment.
View Part B contact information with any questions regarding the HPSA bonus payment.
Page Last Updated: Thursday, 18-Mar-2010 05:56:00 CDT
