CurrentAnthemPolicy C-11002

'Incident to' Services - Professional

Defines Anthem's reimbursement and billing requirements for 'Incident to' professional services, including eligibility, supervising provider criteria, and billing modifiers; applies to Anthem Blue Cross and Blue Shield commercial providers and members.

Policy Summary

PayerAnthem

Policy'Incident to' Services - Professional

Policy CodePolicy C-11002

Change TypeNo material change

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSupervising provider must be physically present in the office suite or immediately available via interactive communication and must document review of each service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15% reductionReimbursement reduction

SARequired modifier

PC/TC 5Facility exclusion

NPPs (NP, PA)Applies to

Incident to Coverage Criteria

Incident to services are eligible for reimbursement only when all supervising, billing and eligibility conditions are met; certain services are excluded.

ALL of the following

ALL of the following
- Rendering provider must be ineligible to submit claims directly to the Health Plan for Incident to reimbursement to be billed under the supervising provider's NPI.
- Examples of ineligible rendering providers
  - Provider is an auxiliary or qualified office personnel as determined by the Health Plan and therefore not eligible to directly submit claims.
  - Provider is in the process of applying for their own NPI (not yet assigned) and not recognized by the Health Plan as eligible to submit claims.

Policy Summary

PayerAnthem

Policy'Incident to' Services - Professional

Policy CodePolicy C-11002

Change TypeNo material change

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSupervising provider must be physically present in the office suite or immediately available via interactive communication and must document review of each service.

SourceLink

On This Page

ALL of the following

Supervising provider must be physically present in the office suite and/or immediately available, when necessary via interactive communication, to provide assistance and direction throughout the E/M visit or other rendered service.
Supervising provider must remain actively involved in the ongoing care of the member.
Supervising provider must document in the medical record that they reviewed the documentation for each service the NPP or auxiliary personnel was involved with.
Group practice note: For group practice providers, any provider within the group who is recognized by the Health Plan as eligible to submit claims directly may qualify as the supervising provider.

ALL of the following

Any services provided by ambulance or Emergency Medical Technicians (EMT) performed under telephonic supervision of a physician or other qualified health care provider.
Services rendered by any provider who is eligible to directly submit claims to the Health Plan (including provider types recognized by the Health Plan even if awaiting an NPI).
Services performed by non-licensed health care providers when licensure is required by the Health Plan or the state in which the Health Plan operates.
Incident to services or supplies that are essential to the performance of a professional service are considered bundled into the primary service and are not separately reimbursable.
Services identified with PC/TC Indicator 5 are considered Incident to services and are not allowed for reimbursement when billed by a professional provider in a facility setting.

Coding and Reimbursement Details

Related CodingModifier

SA	Modifier required when the supervising physician is billing on behalf of Non-Physician Practitioner (NPP) for non-surgical services.

Facility Setting CodingmixedNot Covered

PC/TC Indicator 5

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

inv-04: Reimbursement adjustment - Incident to services

Reimbursement adjustmentIncident to services reimbursed at a 15% reduction of the supervising provider's fee schedule maximum allowance.

Eligibility for supervising provider NPIIncident to reimbursement allowed under supervising provider's NPI only when the rendering NPP or auxiliary personnel is ineligible to submit claims directly to the Health Plan (e.g., applying for an NPI).

Providers with NPI must bill under own NPIAny physician or NPP that has an NPI and is recognized by the Health Plan as eligible to submit claims must report services under their own NPI; Health Plan does not follow CMS rules for providers assigned or awaiting an NPI.

Supervision, Billing and Modifier Requirements

Documentation Required

Supervision and Documentation Requirements

Incident to services billed under the supervising provider's NPI are reimbursable with a 15% reduction of the supervising provider's applicable fee schedule when billed in accordance with this policy. The Health Plan requires that supervising providers be physically present in the office suite and/or immediately available via interactive communication to provide assistance and direction throughout the E/M visit or other rendered service, remain involved in the member's ongoing care, and document review of the NPP's or auxiliary personnel's documentation for each service. For group practices, any provider within the group recognized by the Health Plan as eligible to submit claims directly may qualify as the supervising provider.

Supervising provider must be physically present in the office suite and/or immediately available via interactive communication during the service.
Supervising provider must remain involved in ongoing care and document review of each service provided by the NPP or auxiliary personnel.
Any provider in a group practice recognized by the Health Plan as eligible to submit claims may act as supervising provider.

Billing Rule

Modifier and Eligibility Rule

The Modifier and Eligibility Rule: When a supervising physician bills for non-surgical Incident to services rendered by a Non-Physician Practitioner (NPP) who is ineligible to submit claims directly to the Health Plan (for example, a provider in the process of applying for an NPI or otherwise not recognized by the Health Plan for direct billing), the supervising physician must append Modifier SA to all claim submissions identifying nonsurgical Incident to billing. 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 and are not eligible for Incident to reimbursement. Services provided by ambulance/EMT under telephonic supervision, services rendered by any provider eligible to directly submit claims, services by provider types eligible for an NPI while they are waiting to receive that NPI/Health Plan eligibility, and services by non‑licensed providers who do not qualify as auxiliary personnel are not eligible for Incident to reimbursement.

Append Modifier SA to all claim submissions identifying nonsurgical Incident to billing when the supervising physician bills for NPP services.
Providers who have an NPI and are recognized by the Health Plan must bill under their own NPI; they are not eligible for Incident to reimbursement.
Incident to reimbursement is not allowed for: ambulance/EMT services under telephonic supervision; providers eligible to directly submit claims; providers awaiting an NPI who are otherwise eligible to receive one; non‑licensed providers who do not qualify as auxiliary personnel.

Policy Definitions

inv-07: Auxiliary personnel

DefinitionAuxiliary personnel are personnel who, as determined by the Health Plan, are not eligible to directly submit claims to the Health Plan and therefore are not eligible to receive direct reimbursement.

RolePerform services that may be integral to patient care under direct supervision of a physician or other qualified health care professional.

Claim submission eligibilityAuxiliary personnel themselves are not eligible to submit claims directly to the Health Plan; services must be billed under an eligible supervising provider when criteria are met.

inv-08: 'Incident to' Services

Definition'Incident to' Services are certain services integral to the care of a patient performed by auxiliary personnel under direct physician or other qualified health care professional supervision.

Supervising provider involvementSupervising provider must be physically present in the office suite or immediately available via interactive communication, remain involved in ongoing care, and document review of each service provided by the NPP or auxiliary personnel.

Billing relationshipIncident to services may be reimbursed under the supervising provider's NPI when the rendering provider is ineligible to submit claims directly to the Health Plan; providers with their own NPI must bill under their own NPI.

inv-09: Non-Physician Practitioner (NPP)

DefinitionNon-Physician Practitioner (NPP) includes Nurse Practitioners (NP) and Physician Assistants (PA) for the purpose of this policy.

Scope of practiceNPPs must act within the scope of practice of their license and/or certification and in accordance with applicable state law.

Supervisory roleNPP providers are qualified to assist a physician or another qualified health care provider or act in the place of such individuals without direct supervision when permitted by state law.