Overview
If you’re participating in Pearl’s ACO through the Direct Contracting model, you’ll continue billing Medicare the same way you always have—but there are some key differences in how primary care services appear on your Explanation of Benefits (EOBs).
Key benefits / use cases
No change in billing process – Continue submitting Medicare claims as usual.
Primary care payments included in PBPM – Some services will show as paid at $0, but that’s expected.
Clear EOB indicators – Look for reason code “132” to confirm the service was included in your monthly payment from Pearl.
Fee-for-service remains – Non-primary care services will still be reimbursed as usual.
How to bill under the Direct Contracting model
Step-by-step process
Submit claims to Medicare as you normally would for all services rendered.
Expect $0 payments on EOBs for certain primary care services included in your monthly PBPM (Per-Beneficiary-Per-Month) payment from Pearl.
Check your EOB for reason code 132: Prearranged demonstration project—this confirms the service is part of the model and was prepaid.
Look for readjustments if a patient’s alignment status changes. Medicare may re-adjudicate prior claims and pay the full amount in the following month.
Continue billing non-primary care services under traditional Medicare fee-for-service—they’ll be reimbursed normally.
Example of how this appears on your EOB
Here’s a sample from a participating practice’s EOB:
The initial remittance advice showed full payment.
Later, Medicare reprocessed the claim, reflecting participation in the model with the 132 reason code.
As a result, the practice received two statements: one before and one after Medicare’s update.
FAQs
What is the “132: Prearranged demonstration project” code?
This code appears on EOBs to indicate that a service was covered through a demonstration project like Pearl’s ACO. It confirms the payment was already included in your monthly PBPM and prevents duplicate reimbursement.
Will I always receive two remittance statements?
Not necessarily. You may receive two statements during system updates or alignment changes, but typically Medicare will issue a single, adjusted remittance advice once their systems are current.
Do I need to change how I submit claims?
No. Continue submitting claims to Medicare as you normally would. Pearl’s model doesn’t require a different billing process—it just affects how some services are reimbursed.