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Reminder: Capitation Guidelines and the Importance of Specialty Subcontractor Arrangements

When ordering services for HMO and POS members and Direct POS members (to receive the highest level of benefits), the ordering provider (including specialists) must utilize the designated (capitated) site selected by the member’s primary care physician (PCP) for these services:

• diagnostic radiology (southern New Jersey only);
• laboratory (all states, all counties);
• podiatry (Pennsylvania only);
• short-term rehabilitation (southern New Jersey only; physical therapy only capitated in New Castle County, Delaware).

As outlined in the Provider Manual for Participating Professional Providers (Provider Manual), PCPs must refer members to their designated site for capitated services. Referring members to a site other than their PCP’s designated site for these services is not permitted. Please refer to the Provider Manual for more information.

If you are a provider who is contracted for specialty capitation for one of the above services, you are required to either provide that service or arrange for the service through a subcontractor arrangement. Therefore, it is imperative that you seek out an arrangement with a participating subcontractor and maintain that arrangement in order to serve your AmeriHealth HMO, POS, and Direct POS patients. If you do not already have participating subcontractors in place, please take steps to establish an arrangement.

Read more about capitation requirements by viewing the claim payment policies on capitation for each of the services listed. To do so, go to www.amerihealth.com/medpolicy and type the name of the service in the Search box.

For more information about subcontractor arrangements, contact your Network Coordinator or Hospital/Ancillary Services Coordinator. If your AmeriHealth patients have questions about capitated services, please have them call Customer Service at 1-800-275-2583.