Primary Care Provider Self Attestation Form
Changes to Medicaid primary care reimbursement were enacted as part of the Affordable Care Act. Eligible physicians will receive supplemental payments for services rendered between January 1, 2013, and December 31, 2014, that raise the Medicaid reimbursement to Medicare rates.
To be eligible for the increased payment, physicians must personally attest as practicing in family medicine, general internal medicine and/or pediatric medicine and be board certified or meet thresholds for providing recent primary care services. Advanced practice professionals practicing under the personal supervision of a qualified physician are eligible to receive the supplemental payment.
Providers must fill out the short Self-Attestation Form in order to be eligible for the supplemental payments.
Supplemental payments will be from the date of self-attestations.
Contact information (phone numbers and mailing addresses) for Xerox State Healthcare (the Department’s fiscal agent) is available for the following:
• Billing and Bulletin Questions
• Correspondence, Inquiries, and Adjustments
• Enrollment, Changes, Signature authorization and Claim Requisitions
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