CurrentBlue Cross Blue Shield - NevadaPolicy C-20001

Nurse Practitioner and Physician Assistant Services - Professional

Defines Blue Cross Blue Shield - Nevada's reimbursement approach for services provided by nurse practitioners (NPs) and physician assistants (PAs), including when payment reductions apply and which services are exempt; applies to professional providers submitting claims to the health plan.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyNurse Practitioner and Physician Assistant Services - Professional

Policy CodePolicy C-20001

Change TypeNo material change

Effective Date02/01/2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines and submit claims with the NP/PA NPI as the rendering provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3exempt service types

multiplestate-specific exemptions

C-20001policy id

02/01/2025effective

03/12/2025last review

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Reimbursement Criteria for NP and PA Services

NP/PA reimbursement criteria

Reimbursement stance and conditions for NP and PA professional services.

The health plan allows reimbursement for services provided by Nurse Practitioners (NPs) and Physician Assistants (PAs) unless provider, state, federal contracts and/or mandates indicate otherwise.

ALL of the following

The service is considered a physicians' service.
The service is within the NP or PA provider's scope of practice.
A payment reduction consistent with CMS reimbursement is applied.

Services exempt from the payment reduction

Drugs
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Laboratory Services and Laboratory Screening Tests

Billing instruction: Services furnished by the NP or PA should be submitted with their own NPI as the rendering provider.

State-specific exemptions (examples): State exemptions and variations may apply; examples include Colorado, Kentucky, Maine, Nevada, Ohio, Georgia, and others with differing application of payment reductions or use of the applicable established fee schedule.

Authorization, Medical Necessity, and Claims Compliance

Prior Authorization

Obtain authorization and confirm medical necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence.

Denial Risk

Follow coding and billing requirements or face claim actions

If appropriate coding/billing guidelines or current reimbursement policies are not followed, claims may be rejected or denied and payments may be recovered.

Claims may be rejected or denied.
The plan may recover and/or recoup claim payment.

Key Definitions

Definitions — General Reimbursement Policy Definitions

Scope of definitionsGeneral Reimbursement Policy Definitions (see policy for full definitions).

ApplicabilityDefinitions apply to reimbursement policies throughout this document, including NP and PA services, coding, billing and payment rules.

Reference noteSee full policy text for specific term definitions and legal references; this entry provides a general pointer to the definitions section.

LocationDefinitions are consolidated in the policy's Definitions section for consistency across reimbursement rules.