CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Fee-for-Time Compensation Arrangements (substitute physicians/providers)

Administrative guidelines governing when a participating physician/provider may bill Blue Cross & Blue Shield of Rhode Island for services rendered by a substitute physician/provider (fee-for-time arrangements) and the requirements for such arrangements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFee-for-Time Compensation Arrangements (substitute physicians/providers)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07|17|2012

Next Review Date

Key ActionAppend HCPCS modifier Q6 to each procedure code and notify BCBSRI in writing while emailing proof of substitute licensure, liability insurance, and training/board certification to Database.Credentialing@bcbsri.org.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysmaximum continuous substitution period without separate credentialing

Q6required HCPCS modifier

Not applicablePrior authorization

Not applicableMedical criteria

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Coverage criteria for substitute physician/provider billing

Covered when ALL of the following conditions are met:

ALL of the following

Regular physician/provider is unavailable to provide the visit services.
Regular physician/provider pays the substitute physician/provider for his/her services and guarantees that members are not charged for services beyond allowed member cost sharing.
Regular physician/provider notifies BCBSRI in writing of the intent to use a substitute physician/provider.
Regular physician/provider identifies the substitute and emails proof that the substitute is licensed in the state of practice, carries liability insurance consistent with BCBSRI requirements, and possesses training/board certification in the same field as the regular physician/provider to Database.Credentialing@bcbsri.org.
Regular physician/provider documents agreement that the substitute may not charge members for services or report services to BCBSRI in any other manner than outlined in these policies.
The substitute physician/provider does not provide the visit services continuously for longer than 60 days (limit is 60 days per 12-month period); substitutions beyond 60 days require the substitute to be contracted and credentialed by BCBSRI.
Maximum substitution duration: 60 days per 12-month period.
Claims for services rendered by a substitute physician/provider are submitted under the regular contracted physician/provider's name and Tax Identification (ID) number with HCPCS modifier Q6 appended to each procedure code to identify substitute services.
Services of non-physician practitioners or Advance Practice Providers (e.g., CRNAs, NPs, PAs) may not be billed under fee-for-time compensation arrangements.
If only postoperative services during a global period are provided, they need not be identified on the claim as substitution services; services inclusive of the global payment are not separately reported.
All arrangements for substitute physician/provider use must be approved by BCBSRI before implementation; failure to follow procedures constitutes subcontracting and may result in termination.

Modifier and Duration Coding Details

Substitute physician/provider modifierModifierCovered

Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area

Maximum substitution duration

Maximum substitution duration60 days per 12-month period

Consequence if exceededSubstitute providing services for more than 60 days must be contracted and credentialed by BCBSRI

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

Notification, Documentation, Billing, and Limits

Documentation Required

Notification, documentation, and billing when using a substitute physician/provider

Append HCPCS modifier Q6 to each procedure code to identify services furnished by a substitute physician/provider. Notify BCBSRI in writing of intent to use a substitute and email proof that the substitute is licensed in the state of practice, carries liability insurance consistent with BCBSRI requirements, and possesses training/board certification in the same field as the regular physician/provider to Database.Credentialing@bcbsri.org. Submit claims under the regular contracted physician/provider's name and Tax Identification number with Q6 appended.

Append modifier Q6 after the procedure code to indicate substitute services.
Notify BCBSRI in writing before using a substitute.
Email proof of substitute licensure, liability insurance meeting BCBSRI requirements, and training/board certification to Database.Credentialing@bcbsri.org.
Submit claims under the regular provider's name and TIN.

Billing Rule

Duration limit and credentialing requirement

Limit use of a substitute physician/provider to 60 days per 12‑month period. If a substitute provides services for more than 60 days, the substitute must be contracted and credentialed by BCBSRI before continuing.

60-day limit applies per 12-month period.
Substitutes exceeding 60 days must be contracted and credentialed by BCBSRI.

Denial Risk

Subcontracting is prohibited — noncompliance may lead to termination

BCBSRI does not permit subcontracting; failure to follow the substitute-use procedures or subcontracting services is a contractual violation and may result in termination of the agreement.

All arrangements for substitute use must be approved by BCBSRI before implementation.
Failure to follow procedures or subcontract constitutes cause for termination.

Key Definitions

Definition — regular physician/provider

Who qualifies as a regular physician/providerMDs or DOs; may include physician specialists (e.g., cardiologist, oncologist, urologist)

Billing responsibilityRegular physician/provider may bill BCBSRI and receive payment for substitute services when policy conditions are met

Restriction on non-physician practitionersServices of non-physician practitioners/Advance Practice Providers may not be billed under fee-for-time arrangements

Definition — substitute physician/provider services

How services are billedClaims submitted under the regular contracted physician/provider's name and Tax Identification (ID) number

Required modifierAppend HCPCS modifier Q6 to each procedure code to identify substitute physician/provider services

Identification on claimRegular physician/provider must identify services as substitute physician/provider services meeting policy requirements