CurrentAnthemPolicy CRHPAP - 001

Physician Extender Reimbursement Policy

Reimbursement policy for services rendered by physician extenders (Physician Assistants, Nurse Practitioners, Nurse Midwives) within Anthem Blue Cross and Blue Shield Central Region for IN, KY, MO, OH, WI.

Policy Summary

PayerAnthem

PolicyPhysician Extender Reimbursement Policy

Policy CodePolicy CRHPAP - 001

Change TypeNo material change

Effective DateOct 1, 2016

Next Review Date

Key ActionReimburse physician extenders at the lesser of billed charges or 85% of the physician fee schedule, with specified exceptions reimbursed at 100%.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

85%standard percent of physician fee schedule used to reimburse physician extenders

100%percent of fee schedule reimbursed for specified services

IN, KY, MO, OH, WIstates governed

PAs, NPs, NMsprovider types covered

Physician Extender Reimbursement Rules

Physician Extender Reimbursement Criteria

Covered when the following reimbursement rules apply to Physician Assistants (PA), Nurse Practitioners (NP) and Nurse Midwives (NM) in the listed Central Region states.

Policy applies to Anthem Blue Cross and Blue Shield Central Region plans in Indiana (IN), Kentucky (KY), Missouri (MO), Ohio (OH) and Wisconsin (WI).

Physician Assistants, Nurse Practitioners and Nurse Midwives are reimbursed at the lesser of billed charges or 85% of the charge listed in Central Region's applicable physician fee schedule.

Exceptions reimbursed at 100%

Lab tests
X-rays

Policy Summary

PayerAnthem

PolicyPhysician Extender Reimbursement Policy

Policy CodePolicy CRHPAP - 001

Change TypeNo material change

Effective DateOct 1, 2016

Next Review Date

Key ActionReimburse physician extenders at the lesser of billed charges or 85% of the physician fee schedule, with specified exceptions reimbursed at 100%.

SourceLink

On This Page

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Codes, Exceptions, and Reimbursement Thresholds

Exceptions reimbursed at 100%mixedCovered

	lab tests
	x-rays
	all supply codes
	all HCPCS codes
	immunizations and blood draws

Standard reimbursementmixedCovered

All other services performed by Physician Assistants, Nurse Practitioners and Nurse Midwives reimbursed at the lesser of billed charges or 85% of the charge listed in Central Region's applicable physician fee schedule.

Reimbursement threshold — lesser of billed charges or percentage of applicable provider fee schedule

Standard reimbursementLesser of billed charges or 85% of the charge listed in Central Region's applicable provider/physician fee schedule.

Exceptions reimbursed at 100%Lesser of billed charges or 100% of the charge listed in Central Region's applicable provider fee schedule for: lab tests; x-rays; all supply codes; all HCPCS codes; immunizations and blood draws.

Geographic scopeApplies to Anthem Blue Cross Blue Shield Central Region plans in Indiana (IN), Kentucky (KY), Missouri (MO), Ohio (OH), and Wisconsin (WI).

Billing and Authorization Notes for Providers

Billing Rule

Reimbursement basis — no authorization specified

No prior authorization is required for services delivered by physician extenders (PAs, NPs, NMs). Reimbursement for physician extenders is based on the lesser of the provider's billed charge or a percentage of Central Region's applicable provider/physician fee schedule as specified below.

Reimbursement basis: PAs, NPs and NMs are reimbursed at the lesser of billed charges or 85% of the charge listed in Central Region's applicable physician fee schedule.
Exceptions reimbursed at the lesser of billed charges or 100% of the charge listed in Central Region's applicable provider fee schedule: lab tests; x-rays; all supply codes; all HCPCS codes; immunizations and blood draws.

Key Definitions

Physician extenders — definition

DefinitionNon-physicians licensed/certified to perform certain services typically performed by a physician, including Physician Assistants (PA), Nurse Practitioners (NP) and Nurse Midwives (NM).

RolePermitted to provide services that may be reimbursed under this policy when billed by a physician extender.

Reimbursement basis noteServices performed by physician extenders are reimbursed based on the maximum allowable amount, except as otherwise specified.

Maximum allowable amount — definition

Definition of maximum allowable amountThe maximum allowable amount is the lesser of billed charges or a percentage of the amount listed in Central Region's applicable provider fee schedule and includes deductibles, copayments and coinsurance.

Includes member financial responsibilityMaximum allowable amount includes deductibles, copayments and coinsurance.

Applied to physician extendersUsed as the reimbursement basis for services rendered by PAs, NPs and NMs, subject to the percentage rules in this policy (85% standard; 100% exceptions).