Current Provider Type and Specialty Logic- Effective 1/1/2024
In addition to meeting other criteria from the primary care sub-capitation claims logic, the servicing or attending provider must have at least one specialty from the Included Provider Specialties list below and none from the Excluded Provider Specialties list below. There are several provider specialties that are not on either list. These unlisted specialties have no impact on whether a claim is covered by primary care sub-capitation. Note that Community Health Centers follow a separate process; please see the section Provider Type and Specialty for details.
At least one of the following specialties:
| Included Provider Specialties |
|---|
| Adolescent Medicine |
| Family Medicine |
| General Medicine |
| Geriatric Medicine |
| Internal Medicine |
| Nurse Practitioner |
| Pediatric Medicine |
| Physician Assistant |
| Preventive Medicine |
| Osteopathic Medicine |
Must not have one of the following specialties:
| Excluded Provider Specialties |
|---|
| Anesthesiology |
| Critical Care |
| Dermatology |
| Gastroenterology |
| Hematology |
| Nephrology |
| Neurology |
| Nuclear Medicine |
| Oncology |
| Ophthalmology |
| Otolaryngology |
| Pain Medicine |
| Pathology |
| Physical Medicine and Rehabilitation |
| Physical Therapy |
| Psychiatry |
| Pulmonology |
| Radiology |
| Rheumatology |
| Surgery |
| Urology |
Note: Sub-specialties are included or excluded according to their overarching specialty (e.g., sub-specialties like “Pediatric Surgery” are excluded under “Surgery”). Specialties not on the “included” or “excluded” lists above do not impact the Primary Care Sub-Capitation claims logic.
Archived Provider Type and Specialty Logic
| Date published: | July 1, 2024 |
|---|