Intro to Provider Type and Specialty
Provider type refers to the type of practice site (e.g., outpatient hospital, group practice), while provider specialty refers to the specialty of an individual clinician (e.g., internal medicine, pediatrics). Both are important to the claims logic that MassHealth uses to determine which claims are covered by the Primary Care Sub-Capitation Program. Please note: Community Health Centers follow a separate process, as described in the Community Health Centers section below.
To be covered by primary care sub-capitation, claims must
- be for a member enrolled in a MassHealth ACO,
- have the tax identification number (TIN) of the practice site the member is attributed to
- have one of the CPT codes included in the primary care sub-capitation service code set, and,
- follow MassHealth’s provider type and specialty logic, outlined below.
Claims that are covered by primary care sub-capitation according to this logic are “zero paid,” which means that those claims are still submitted but no payment will be issued for the claims. For more details, see the section How Practices Get Paid. Claims covered by primary care sub-capitation are also included in the historical base that MassHealth uses to develop sub-capitation per-member, per-month rates. For more details, see the section Rate Methodology.
Provider Types
Provider type is one of the criteria that MassHealth uses to determine which claims are covered by primary care sub-capitation. To be covered, claims must come from one of the qualifying MassHealth provider types listed below:
- Individual Practitioners
- Physicians
- Nurse Practitioners
- Physician Assistants
- Group Practice Organizations
- Outpatient Hospitals
- Hospital Licensed Health Centers
- Community Health Centers
MassHealth determines provider type based on information included in claims and provider tax identification registration.
Provider Specialties
Provider specialty is an additional criterion that MassHealth uses to determine which claims are covered by the Primary Care Sub-Capitation Program. In addition to meeting the criteria above, to be covered by the primary care sub-capitation program, the servicing or attending provider must have at least one included specialty from MassHealth’s included provider specialties list and must not have any excluded specialty from the excluded provider specialties list.
Included provider specialties are those that mostly deliver primary care rather than specialty care. Select examples of included provider specialties are internal medicine, pediatrics, family practice, family medicine, and geriatric medicine.
Excluded provider specialties are those that mostly deliver specialty care. Select examples of excluded provider specialties are anesthesiology, dermatology, psychiatry, radiology, surgery, and physical therapy.
There are also provider specialties that have no impact on the primary care specialty logic. Select examples of provider specialties that have no impact on the primary care specialty logic include infectious diseases, endocrinology, cardiology, gynecology, and obstetrics.
For the full list of specialties, go to Included/Excluded Provider Specialties.
For providers enrolled in one of MassHealth’s Primary Care ACOs (PCACOs), provider specialty data is pulled from information in MMIS and the Board of Registration in Medicine (BORIM). For providers enrolled in an Accountable Care Partnership Plan (ACPP) ACO, ACOs will collect specialty information from their providers and share this with MassHealth. Providers should reach out to their ACO to address any questions or issues regarding specialty data.
Community Health Centers
The provider specialty logic described above does not apply to primary care services delivered at community health centers. For community health centers, all CPT codes on the included list are covered by primary care sub-capitation, irrespective of the specialty of the clinician delivering the services, so long as all other conditions of the sub-capitation claims logic are met.