You will continue to bill Medicare in the same way as you do now, the distinction being that claims for certain primary care services included in the PBPM will come back zeroed out. There is a more elaborate version on page 17-18 here, but essentially, Medicare will pay the reduction for any assigned patients. If they determine that they paid a reduced amount for patients no longer assigned, they’ll re-adjudicate to pay the full amount in the following month. Any non-primary care services will be reimbursed fee-for-service as they are now.

Primary care services included in your monthly payment from Pearl will reflect the reason code "132: Prearranged demonstration project" on the explanation of benefits (EOB), to avoid duplicative payments for the same patient and services. Below is a sample statement that providers better insight around changes Pearl providers can anticipate in their upcoming EOB. Please note, this practice received their initial remittance advice statements from Medicare without the adjustment, likely when Medicare was still updating their systems to reflect participation in the model. The subsequent readjusted statement was reprocessed and updated with the “132” code. Therefore, you may receive two statements: