Nurse Practitioner and Physician Assistant Services, Reimbursement Policy
Defines Anthem's reimbursement stance for services performed by nurse practitioners (NPs) and physician assistants (PAs) and describes when payment reductions consistent with CMS apply; affects providers submitting claims to Anthem Blue Cross Medicare Advantage in applicable states.
No material clinical or coverage changes in this revision.
Reimbursement Criteria for NP and PA Services
Reimbursement criteria for NP/PA services
Anthem allows reimbursement when all of the following are met:
ALL of the following
- The service is considered a physician's service.
- The service is within the practitioner’s scope of practice.
- A payment reduction is consistent with CMS reimbursement.
- The service is not one of the excluded categories subject to no payment reduction: drugs; Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); laboratory services and laboratory screening tests.
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.