Notification

Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)


Notification Issue Date: 11/01/2017

This policy becomes effective 12/01/2017:

This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.



Claim Payment Policy


Title:Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)

Policy #:00.10.40b

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Services performed on a fee-for-service (FFS) basis by a certified registered nurse practitioner (CRNP) or Physician Assistants (PA) will be reimbursed based on the terms of their professional provider contract. Payment for services rendered are based on 85 percent of the standard physician fee schedule.

This policy does not apply to hospital based specialties (e.g. Hospitalist, Emergency room, radiologist, neonatology) and urgent care practices.

For products with primary care provider capitation, services rendered by a CRNP or PA working in a primary care group are considered part of capitation, with the exception of those services outlined in the Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physician (PCP) Policy.

Covered vaccines are eligible for reimbursement consideration by the company at 100 percent of the standard vaccine and injectable fee schedule.
Guidelines

Refer to the Professional Provider Credentialing requirements located on the Company’s website for information regarding certified registered nurse practitioners (CRNPs) and Physician Assistants (PAs) participation in our network.

Description

Certified registered nurse practitioners (CRNPs) and Physician Assistants (PAs) working in primary care or specialty physician groups may bill directly for their services as the performing provider.
References


Provider Contracts




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

REVISION FROM 00.10.40b:
12/01/2017Effective 12/01/2017, Physician Assistants (PAs) are eligible to perform services in in a specialty group.
Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.