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00.10.01an, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Effective date
Apr 1, 2026
Identified
Jul 15, 2026
Summary
Independence Blue Cross added HCPCS code A4318 to the list of services that HMO and HMO-POS primary care providers in Pennsylvania and New Jersey can bill above capitation. This coding update expands the services eligible for fee-for-service reimbursement beyond the standard monthly capitation payment. Billing teams must verify A4318 claims are submitted with proper documentation and routed to the correct attachment (A for PA, B for NJ).
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What to do
Action · 3 steps
01By 04/01/2026: Billing team must update billing system logic to recognize HCPCS code A4318 as an above-capitation service for HMO/HMO-POS primary care providers in Pennsylvania (Attachment A) and New Jersey (Attachment B).
02Update claim scrubbing rules to verify medical necessity documentation is attached before submission.
03Train billing staff to route A4318 claims correctly based on member state.
If missed: Failure to properly code and document A4318 claims may result in denials or recoupment.
Codes mentioned
A4318
Original notice
00.10.01an, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
medpolicy.ibx.com · Always check the source before changing claims.
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