Incentive for Specialty Providers

HPSM offers an incentive for specialty providers  contracted with  Medi-Cal, HealthWorx, CareAdvantage and primary care providers that increases Medi-Cal allowable rates of 175% for certain Medi-Cal specialties. HPSM developed the program to improve access to specialty care, increase utilization, enhance payment data and align reimbursement with market trends. Injectables are not eligible to receive the 175% markup.

Claims submitted without the appropriate taxonomy code and qualifier code (ZZ or PXC) will pay at the current rate (123% of the allowable Medi-Cal rate). HPSM will not accept claims resubmitted to include the taxonomy code.

About taxonomy codes

Taxonomy codes are administrative codes set for identifying the provider type and area of specialization for health care providers. Each taxonomy code is a unique ten-character alphanumeric code that enables providers to identify their specialty at the claim level.

Taxonomy codes are used when applying for a National Patient Identifier (NPI) with the National Plan and Provider Enumeration System (NPPES).


Claims submissions

The Specialists Incentive Program will require all selected specialists to include their taxonomy code on the claims form when submitting a paper CMS 1500 claims forms or electronic claims submission (837 files).

  • Paper Claims: Enter the taxonomy code in box 33b of the CMS1500 form.
  • Electronic Claims (837 file): On the incoming electronic file (837), the segment is “PRV”, on different location/loop with different Code, For Billing / Submitting, loop 2000A, Code “BI” example: PRV*BI*PXC*207N00000X~