CommercialReimbursementHigh impact
00.10.01al, Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Independence Blue Cross·Family Medicine, General Practice, Internal Medicine·Medical Policy
Effective date
Jan 1, 2025
We identified it
Jun 19, 2026
Summary
Policy 00.10.01al defines which services provided by HMO and HMO-POS primary care providers are paid above capitation (i.e., on a fee-for-service basis rather than included in the capitated rate). This recent policy, effective 01/01/2025, clarifies billing and payment methodology for primary care services under capitated arrangements. Billing teams must understand which services bypass capitation to ensure correct claim submission and reimbursement.
Action Required
By 03/17/2025 (30 days from policy posting): Billing team must review the full policy text at the provided URL to identify which specific CPT/HCPCS codes are designated as 'paid above capitation' for HMO and HMO-POS plans. Update billing system edits and claim submission logic to bill these services on a fee-for-service basis rather than including them in capitation. Audit encounter forms and provider education materials to ensure primary care providers understand which services generate additional claims versus services included in their capitated payment. Failure to correctly identify and bill above-capitation services will result in underbilling and lost revenue. If the policy text is not accessible online, contact the payer's contracting department immediately to obtain the complete list of affected service codes.