Capitated Medical Case Management

For large or catastrophic claims, an insurer may negotiate with a medical case management vendor to pay a flat fee or lump sum for complete medical care of a claimant for a specified time frame. The vendor manages the care and issues all payments for medical costs directly to the medical providers. In this situation, the insurer or authorized Submitter must report the medical bill detail as a separate medical data call record as outlined in the California Medical Data Call Reporting Guide.

Capitated Physical Medicine Treatment

For long term physical medicine treatment, an insurer may negotiate with a physical medicine provider to pay a flat fee/lump sum for all physical medicine treatments of a claimant for a specified time frame. If the physical medicine provider does not provide the medical bill detail for each individual treatment, the insurer or authorized Submitter may report the lump sum payment as a single medical transaction data record. The Service Dates should define the entire length of treatment for the claimant and should use CPT Code '97799' ("unlisted physical medicine service or procedure") as the Paid Procedure Code. However, if the physical medicine provider does provide the treatment detail, the detail of each treatment must be submitted as a separate medical data call record.