Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Reimbursement For Advanced Practice Provider Services

Policy #:

MA00.056

Policy

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 policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

This policy does not apply to professional providers in urgent care practices.

Medically necessary services performed by an Advanced Practice Provider (APP) (e.g., Certified Registered Nurse Practitioners (CRNP), Physician Assistants (PA), Certified Nurse Midwives (CNM)) may be covered and eligible for reimbursement consideration by the Company. For information regarding CRNA services, please refer to the Reporting and Documentation Requirements for Anesthesia Services policy, 00.01.14.

Services performed by an APP, incident to a physician’s services, using the physician’s NPI, will be reimbursed at 85 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement.

Services performed by an APP, reporting under their own NPI, will be reimbursed in accordance with the specific terms and conditions of the participation agreement.

Covered vaccines and injectables are eligible for reimbursement consideration by the Company in accordance with the standard vaccine and injectable fee schedule.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Services performed by an APP who has completed the credentialing process must be reported using their own NPI.

Services performed by an APP, incident to a physician service, must be reported under the physician’s NPI and appended with Modifier SA or SB.

Guidelines

Refer to the Professional Provider Credentialing requirements located on the Company’s website for information regarding participation and credentialing of CRNPs and PAs in the Company’s network.

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) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers policy.

Description

Advanced Practice Providers (APP) are healthcare professionals who have undergone specialized education and training. Examples of APPs include but are not limited to: physician assistants, nurse practitioners, certified nurse midwives, etc.

Incident to services are those services that are furnished "incident to" physician professional services in the physician's office or in the individual's home if the individual is homebound. The supervising physician does not need to be physically present in the treatment room while incident to services are provided; however, the supervising physician must provide direct supervision, meaning the supervising physician (or a supervising partner) must be in the same office suite to render assistance if necessary.

Not-incident to services are those personally performed by the APP without direct supervision from a physician.

References

Centers for Medicare and Medicaid Services (CMS). Incident To Services and Supplies. [CMS Website]Available at: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/incident-services-supplies. Accessed October 17, 2025.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 12: Physician and Nonphysician Pracitioners. [CMS Web site]. 2/02/23. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed October 17, 2025.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 15: Covered Medical and Other Health Services. [CMS Website]. 3/16/2023. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed October 17, 2025.

Centers for Medicare & Medicaid Services (CMS). MLN Matters SE0441. [CMS Website]. Available at:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf. Accessed October 17, 2025.

Provider Contracts.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

MODIFIER -SA IS USED TO REPRESENT SERVICES PERFORMED BY CERTIFIED REGISTERED NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS

SA Nurse practitioner rendering service in collaboration with a physician

SB Nurse midwife

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.056:

02/01/2026

The following new policy has been developed to communicate the Company's reimbursement position for services performed by an Advanced Practice Provider incident to a supervising physician at 85% of the physician fee schedule.

Additionally, the policy has been created to clarify the Company's position for APP's performing services that are reported by a supervising physician.

Version Effective Date:

2/1/2026

Version Issued Date: