DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for ...

CMS-1503-FC 853
determining eligibility for most potential primary care practitioners because it allows for
a review of a full year of claims data without delaying incentive payments for most
eligible primary care practitioners.
However, we recognize the special circumstances of newly enrolled potential
primary care practitioners, in that they do not have the claims history from 2 years prior
to the PCIP payment year to determine their eligibility. We believe it is important to give
potential primary care practitioners newly enrolling in Medicare in the year immediately
preceding the PCIP payment year the opportunity to qualify for the PCIP with minimal
delay. Therefore, for these practitioners, we will determine PCIP eligibility based on a
different prior period than for those practitioners who are already enrolled in Medicare
and who have Medicare claims data from 2 years prior to the PCIP payment year
available for analysis. Section 1833(x) of the Act (as added by Section 5501(a) of the
ACA) gives the Secretary the authority to establish the period of allowed charges used to
assess the potential primary care practitioner's primary care percentage with regard to the
minimum 60 percent threshold required for PCIP eligibility. For newly enrolled potential
primary care practitioners only, we will use the available claims data from the year
immediately preceding the PCIP payment year (for example, CY 2010 claims data for
CY 2011 PCIP payment) to determine PCIP eligibility. We will use all claims data
available for the newly enrolled potential primary care practitioner from that prior year to
determine PCIP eligibility, with no minimum time period that the potential primary care
practitioner must have been enrolled in Medicare in that prior year. Therefore, a newly
enrolled potential primary care practitioner would need to wait no more than one year and
potentially significantly less than one year following enrollment and first billing in order