CurrentBlue Cross Blue Shield - MainePolicy C-11002

'Incident to' Services - Professional

Defines Anthem Blue Cross and Blue Shield - Maine's reimbursement approach and billing requirements for 'Incident to' professional services, including eligibility, supervising provider requirements, and modifier use; applies to providers submitting claims to the Health Plan.

Policy Summary

PayerBlue Cross Blue Shield - Maine

Policy'Incident to' Services - Professional

Policy CodePolicy C-11002

Change TypeContent revised and added guidance (modifier, facility exclusions)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionAppend SA modifier when a supervising physician bills non-surgical services performed by an NPP and ensure services are billed under the rendering provider's NPI if they are eligible.

SourceLink

POLICY UPDATE CHANGES

Updated services performed for patients in a facility setting to identify PC/TC indicator 5 services.

Added statement that SA modifier must be appended for non-surgical services when the supervising physician bills on behalf of an NPP.

Reformatted policy content to separate Incident to services from Incident to billing guidelines.

Added Non-Physician Practitioner (NPP) to Definitions section and updated the 'Incident to' definition.

15%Allowance reduction

SARequired modifier

PC/TC 5Facility exclusion

NP, PANPP types

'Incident to' Coverage Criteria

Incident to coverage criteria

Incident to services may be reimbursed under the supervising provider's NPI only when ALL of the following criteria are met; otherwise the rendering provider must bill under their own NPI.

ALL of the following

The rendering NPP or qualified auxiliary office personnel is ineligible to submit claims directly to the Health Plan (for example, not assigned an NPI or not recognized by the Health Plan).
Applies when provider is in process of applying for an NPI; providers with an NPI who are eligible to bill must report services under their own NPI.
Any physician or NPP that has an NPI and is recognized by the Health Plan as eligible to submit claims directly to the Health Plan must report services under their own NPI (Incident to billing not allowed).

ALL of the following

The 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 evaluation and management visit or other rendered service.

Policy Summary

PayerBlue Cross Blue Shield - Maine

Policy'Incident to' Services - Professional

Policy CodePolicy C-11002

Change TypeContent revised and added guidance (modifier, facility exclusions)

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionAppend SA modifier when a supervising physician bills non-surgical services performed by an NPP and ensure services are billed under the rendering provider's NPI if they are eligible.

SourceLink

On This Page

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Coding and Reimbursement Rules

Required modifier for non-surgical NPP services billed by supervising physicianModifierCovered

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

Reimbursement adjustment when Incident to billing used

Reimbursement adjustmentWhen Incident to billing is used, reimbursement is based on a 15% reduction of the supervising provider's maximum allowance.

ApplicabilityApplies when rendering NPP or qualified auxiliary personnel are ineligible to submit claims directly to the Health Plan (including while applying for an NPI).

NPI requirementAny physician or NPP with an assigned NPI and recognized by the Health Plan must report services under their own NPI (not billed Incident to).

Modifier requirementModifier SA must be appended to all claim submissions identifying nonsurgical Incident to billing.

Facility professional billing exclusion

Facility professional billing exclusionServices identified with PC/TC Indicator 5 are considered Incident to and are not allowed for reimbursement when billed by a professional provider in a facility setting.

BundlingIncident to services or supplies essential to a professional service are considered bundled in the primary service and are not allowed for separate reimbursement.

Interaction with NPI rulesIf the rendering provider has an NPI and is eligible to submit claims, services must be reported under that provider's NPI rather than billed as Incident to.

Provider Responsibilities and Billing Actions

Billing Rule

Prior authorization and billing responsibilities

Any physician or NPP that has an NPI and is recognized by the Health Plan as an eligible provider to submit claims directly to the Health Plan is required to report their services under their own NPI. Modifier SA must be appended to all claim submissions identifying nonsurgical Incident to billing when the supervising physician bills on behalf of an NPP. The supervising provider must be physically present in the office suite or immediately available via interactive communication, remain involved in ongoing care, and document in the medical record that they reviewed the documentation for each service the NPP or auxiliary personnel was involved with.

Report services under provider's own NPI if the provider has an NPI and is recognized by the Health Plan.
Append modifier SA to nonsurgical Incident to claims when a supervising physician bills for NPP services.
Supervising provider must be physically present in the office suite or immediately available via interactive communication when necessary.
Supervising provider must document review of each service provided by the NPP or auxiliary personnel and remain involved in ongoing care.

Definitions

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.

Implication for billingServices performed by auxiliary personnel may be billed Incident to under a supervising provider's NPI only when the personnel are ineligible to submit claims directly.

Documentation requirementSupervising provider must document review of each service the auxiliary personnel was involved with in the medical record.

'Incident to' Services

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

Supervising provider presenceSupervising provider must be physically present in the office suite and/or immediately available (including via interactive communication) to provide assistance and direction during the service.

Supervising provider involvementSupervising provider must remain involved in the member's ongoing care and document review of each service performed by the NPP or auxiliary personnel.

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 state law where they practice.

Billing implicationIf an NPP has an assigned NPI and is recognized by the Health Plan as eligible to submit claims, they must report services under their own NPI rather than be billed as Incident to.