CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Fee-for-Time Compensation (Substitute/Locum Tenens) Arrangements

Administrative guidelines governing when and how participating physicians/providers may bill BCBSRI for services furnished by substitute physicians (fee-for-time/locum tenens); applies to participating MD/DO physicians and substitutes in Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFee-for-Time Compensation (Substitute/Locum Tenens) Arrangements

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date07/17/2012

Next Review DateN/A

Key ActionRegular participating physician must notify BCBSRI in writing of intent to use a substitute and submit claims under the regular physician's name/Tax ID with modifier Q6 for substitute services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60max continuous days before credentialing

Q6required modifier

N/Amedical criteria

2013-2021publication history

Coverage Criteria for Substitute Physician Billing

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Coverage criteria for substitute physician billing

Covered when ALL of the following conditions are met:

ALL of the following

The regular physician/provider pays the substitute and guarantees members are not charged beyond allowed member cost sharing.
The regular physician/provider is unavailable to provide the visit services.
The regular physician/provider has notified BCBSRI in writing of the intent to use a substitute physician/provider; arrangements must be approved by BCBSRI before implementation for substitutes exceeding limits.
The regular physician/provider documents agreement that the substitute may not charge members or report services to BCBSRI in any manner other than outlined in policy.
The regular physician/provider identifies the substitute and submits proof that the substitute is licensed in the state of practice, carries liability insurance consistent with BCBSRI requirements, and possesses equivalent training/board certification.
The substitute physician does not provide visit services continuously for longer than 60 days in a 12‑month period; use beyond 60 days requires BCBSRI contracting and credentialing.
Claims for services rendered by a substitute are submitted under the regular contracted physician/provider’s name and Tax ID, with HCPCS modifier Q6 appended to each procedure code to identify the substitute services.
Services of non‑physician practitioners (Advance Practice Providers such as CRNAs, NPs, PAs) may not be billed under fee‑for‑time (substitute) arrangements; see related APP policy.
Participating physicians are responsible for compliance with contract requirements; subcontracting is not permitted and failure to follow procedures may be cause for termination or sanction.

Billing Modifiers and Duration Thresholds

Substitute physician billing modifierModifierCovered

Q6	Service furnished under fee-for-time compensation arrangement by a substitute physician

Substitute duration threshold

Maximum continuous substitute coverage60 days continuous service in a 12‑month period; use beyond 60 days requires BCBSRI contracting and credentialing

Approval requirementAll arrangements for substitute physician use must be approved by BCBSRI before implementation

Contractual responsibilityThe contracted (regular) physician is responsible for substitute adherence to contractual requirements and may be sanctioned for noncompliance

Notification, Approval, and Billing Steps for Substitute Physicians

Prior Authorization

Prior notification, approval, and billing steps when using a substitute physician

The regular participating physician must notify Blue Cross & Blue Shield of Rhode Island in writing of the intent to use a substitute physician and obtain BCBSRI approval of all substitute arrangements before implementation when applicable. Claims for services rendered by the substitute must be submitted under the regular contracted physician's name and Tax ID, with HCPCS modifier Q6 appended to each procedure code to identify the service as furnished by a substitute physician. The regular physician remains responsible for ensuring the substitute is licensed in the state of practice, carries liability insurance consistent with BCBSRI requirements, and possesses equivalent training/board certification; the regular physician must pay the substitute and guarantee members are not charged beyond allowed member cost sharing.

Notify BCBSRI in writing of intent to use a substitute physician (requirement).
Obtain BCBSRI approval of substitute arrangements prior to implementation (all arrangements shall be approved) — especially required when use may approach/exceed limits.
Submit claims under the regular contracted physician/provider name and Tax ID with modifier Q6 appended to each procedure code.
Identify the substitute and submit proof of state licensure, liability insurance consistent with BCBSRI requirements, and training/board certification.
Pay the substitute and guarantee members are not charged except for allowed member cost sharing.
Do not exceed 60 continuous days of substitute coverage in a 12‑month period without BCBSRI contracting and credentialing.

Key Definitions

Substitute physician/provider

DefinitionSubstitute physician/provider: a physician who temporarily renders services for a regular participating physician when that physician is unavailable

Notification and documentationRegular physician must identify the substitute, notify BCBSRI in writing of intent to use a substitute, and submit proof of state licensure, liability insurance, and equivalent training/board certification

Billing relationshipRegular physician pays the substitute and may bill BCBSRI for the substitute's services as though the regular physician performed them when policy conditions are met

Physician/provider

Included practitionersPhysician/provider refers to MDs or DOs, including physician specialists (e.g., cardiologists, oncologists, urologists)

Exclusion of APPsServices of non-physician practitioners (Advance Practice Providers such as CRNAs, NPs, PAs) may not be billed under fee-for-time (substitute) compensation arrangements

Subcontracting prohibitionBCBSRI does not permit subcontracting; participating physicians are responsible for compliance under their contract