Nurse Practitioner and Physician Assistant Services, Reimbursement Policy
Defines Anthem Blue Cross and Blue Shield reimbursement rules for services performed by nurse practitioners (NPs) and physician assistants (PAs), including when payment reductions consistent with CMS apply and which services are excluded. Applies to members and providers under Anthem plans in the states listed in the document, including Nevada.
Moved services not eligible for payment reduction to a stand-alone statement and added laboratory screening tests to the exclusions list.
Reimbursement Criteria and Exclusions
Reimbursement Criteria and Exclusions
Anthem allows reimbursement for services provided by nurse practitioners (NPs) and physician assistants (PAs) when the following criteria are met. Services must also meet authorization and medical necessity guidelines and be billed with appropriate supported codes.
ALL of the following
- The service is within the provider's scope of practice
- Payment reduction, if applied, is consistent with CMS reimbursement
- Services completed by the NP or PA are submitted with their own NPI as the rendering provider
Exclusions (these are NOT considered for payment reduction)
- Durable medical equipment; prosthetics, orthotics, and supplies (DMEPOS)
- Drugs
- Laboratory services and laboratory screening tests
ALL of the following
- Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence
- Services should be billed with CPT, HCPCS, and/or revenue codes and fully supported in the medical record or office notes
ALL of the following
- Policy applies to both participating and non-participating professional providers and facilities unless otherwise noted
ALL of the following
- If appropriate coding/billing guidelines or current reimbursement policies are not followed, Anthem may recover/recoup claim payment, reject or deny the claim, or adjust reimbursement to reflect the appropriate services performed
ALL of the following
- Policy effective 11/01/2024; 09/06/2024 review moved services not eligible for payment reduction to a stand-alone statement and added laboratory screening tests to exclusions
Accepted Coding and Documentation Requirements
| No codes listed |
Billing, Authorization, and Submission Requirements
Billing and Authorization Requirements
Ensure claims use industry-standard CPT, HCPCS, and/or revenue codes and that each billed service is fully supported in the medical record; submit services completed by the NP or PA with the NP/PA's own NPI as the rendering provider. Services must also meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence. Failure to follow coding/billing guidelines may result in recovery/recoupment, claim rejection or denial, or adjustment of reimbursement.
- Bill services with Current Procedural Terminology (CPT), HCPCS, and/or revenue codes that are fully supported in the medical record or office notes.
- Submit NP/PA–performed services with the NP or PA NPI as the rendering provider.
- Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member’s state of residence.
- Noncompliance may lead to recovery/recoupment, claim rejection or denial, or reimbursement adjustment.
Policy Treatment of NP and PA Services
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.