CurrentAnthemPolicy C-11002

Incident to Services and Billing — Professional

Defines Anthem's reimbursement and billing requirements for 'incident to' professional services and supplies, including eligibility, supervising physician criteria, modifier use, and services not eligible for incident to reimbursement. Applies to providers submitting claims to the Anthem commercial health plan.

Policy Summary

PayerAnthem

PolicyIncident to Services and Billing — Professional

Policy CodePolicy C-11002

Change TypeNo material change

Effective DateDec 2, 2025

Next Review Date

Key ActionAppend modifier SA on all claim submissions identifying non-surgical Incident to billing; providers with their own NPI must submit under their NPI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15% reimbursement reduction applied to incident to services

SA requiredmodifier to identify non-surgical Incident to billing

PC/TC 5facility setting not separately reimbursable indicator

NP, PAapplies to NPPs

Incident to — Eligibility and Exclusions

Incident to eligibility and exclusions

Conditions under which incident to services are eligible or ineligible for reimbursement and billing requirements:

Incident to services may be considered for reimbursement under this policy unless superseded by provider, state, federal, or contract requirements.

A 15% reimbursement reduction is applied to the maximum allowance of the applicable supervising physician's fee schedule when services are billed as incident to.

Providers who have been assigned an NPI and are recognized by the health plan as eligible to submit claims directly must report and bill under their own NPI; incident to billing under the supervising physician's NPI is permitted only if the rendering Non-Physician Practitioner (NPP) is ineligible to submit claims directly to the health plan.

Modifier SA must be appended to all claim submissions identifying non-surgical Incident to billing.

ALL of the following

Policy Summary

PayerAnthem

PolicyIncident to Services and Billing — Professional

Policy CodePolicy C-11002

Change TypeNo material change

Effective DateDec 2, 2025

Next Review Date

Key ActionAppend modifier SA on all claim submissions identifying non-surgical Incident to billing; providers with their own NPI must submit under their NPI.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Modifiers, Facility Coding, and Reimbursement Adjustments

ModifierModifier

SA	The SA modifier must be appended when the supervising physician is billing on behalf of Non-Physician Practitioner (NPP) for non-surgical services.

Facility-related codingmixedNot Covered

PC/TC Indicator 5

Services with this indicator are considered Incident to services and are not allowed for reimbursement when billed by a professional provider in a facility setting.

Reimbursement adjustment — Incident to billing

Adjustment applied15% reduction to the maximum allowance of the applicable supervising physician's fee schedule when services are billed as Incident to.

ApplicabilityApplies when Incident to billing services are rendered and billed in accordance with this policy.

Exception — provider NPIThe health plan does not follow CMS Incident to rules for any physician or NPP who has an NPI; providers with an NPI recognized by the plan must submit claims under their own NPI.

Condition for billing under supervising physicianIncident to services may be billed under the supervising physician's NPI only if the rendering NPP is ineligible to submit claims directly to the health plan.

Claim Submission and Modifier Requirements

Billing Rule

Claim submission: append modifier SA and follow NPI billing rules

Append Modifier SA to all professional claim submissions to identify non‑surgical Incident to billing; when a physician or NPP has an NPI and is recognized by the health plan as eligible to submit claims directly, they must bill under their own NPI. Incident to billing under the supervising physician's NPI is only permitted when the rendering NPP is ineligible to submit directly.

Modifier SA must be appended when the supervising physician is billing on behalf of a Non‑Physician Practitioner (NPP) for non‑surgical services.
Any physician or NPP that has an NPI and is recognized by the health plan as eligible to submit claims directly is required to report services under their own NPI.
Incident to services are eligible for reimbursement under the supervising physician's NPI only if the rendering NPP is ineligible to submit claims directly to the health plan.

Key Definitions

Incident to services — definition and requirements

DefinitionIncident to services are services or supplies that are an integral part of a physician's service and services rendered by Non-Physician Practitioners (NPP) billed under the supervising provider's NPI.

Supervising physician requirementsSupervising physician must be physically present and/or immediately available (including via interactive communication), remain involved in ongoing care, and document review of each service the NPP was involved with.

Eligibility noteIncident to services are eligible for reimbursement under the supervising physician's NPI only when the rendering NPP is ineligible to submit claims directly to the health plan.

Ineligible services — examplesServices provided by ambulance/EMT under telephonic supervision and services where the NPP is eligible to bill directly are not eligible for Incident to reimbursement.

Non-Physician Practitioner (NPP) — policy definition

Included practitioner typesFor the purpose of this policy, Non-Physician Practitioners (NPP) include Nurse Practitioners (NP) and Physician Assistants (PA).

Scope of practiceNPPs must act within the scope of practice of their license and in accordance with the state law where the license is held and the NPP practices.

Billing implicationThe SA modifier is used when the supervising physician is billing on behalf of an NPP for non-surgical services, per this policy's definition of NPPs.