CurrentBlue Cross Blue Shield - WisconsinPolicy 001

Physician Extenders Reimbursement Policy

Defines reimbursement policy and applicable payment percentages for physician extenders (PAs, NPs, NMs) within Anthem Blue Cross and Blue Shield Central Region, affecting providers and claims in the named states.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPhysician Extenders Reimbursement Policy

Policy CodePolicy 001

Change TypeNo material change

Effective DateOct 1, 2016

Next Review Date

Key ActionReimburse services provided by PAs, NPs, and NMs at the lesser of billed charges or 85% of the Central Region applicable physician fee schedule, with specified exceptions reimbursed at 100%.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

85%Standard reimbursement percentage for PAs/NPs/NMs in specified states

100%Exceptions reimbursed at full fee-schedule

5Central Region states named

3Physician extenders covered

Physician Extender Payment Criteria

Reimbursement rules for Physician Assistants (PA), Nurse Practitioners (NP), and Nurse Midwives (NM) in the Central Region states; coverage is subject to member program terms and applicable law.

ALL of the following

ALL of the following
- Non-physicians licensed/certified to perform services typically performed by a physician (Physician Assistant, Nurse Practitioner, Nurse Midwife).
  From policy Description.
ALL of the following
- State is one of: IN, KY, MO, OH, WI.

ALL of the following

ALL of the following

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPhysician Extenders Reimbursement Policy

Policy CodePolicy 001

Change TypeNo material change

Effective DateOct 1, 2016

Next Review Date

SourceLink

On This Page

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.

Exceptions (reimbursed at a different percentage)

X-rays are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.
All HCPCS codes are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.
All supply codes are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.
Immunizations are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.
Blood draws are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.

Codes and Reimbursement Rules

HCPCSHCPCSCovered

HCPCS

All HCPCS codes are reimbursed at the lesser of billed charges or 100% of the charge listed in Central Region's applicable provider fee schedule.

Standard physician extender reimbursement

Standard reimbursement rulePhysician Assistants (PA), Nurse Practitioners (NP) and Nurse Midwives (NM) in IN, KY, MO, OH, WI are reimbursed at the lesser of billed charges or 85% of the charge listed in the Central Region applicable physician fee schedule.

Applicable statesIndiana (IN), Kentucky (KY), Missouri (MO), Ohio (OH), Wisconsin (WI).

Provider types coveredPhysician Assistants (PA), Nurse Practitioners (NP), Nurse Midwives (NM).

Payment basisReimbursement is based on the lesser of billed charges or the specified percentage of the Central Region applicable physician fee schedule.

Exceptions reimbursed at full fee-schedule

Exceptions reimbursed at 100%X-rays; all HCPCS codes; all supply codes; immunizations; blood draws are reimbursed at the lesser of billed charges or 100% of the Central Region applicable provider fee schedule.

Scope of exceptionsIncludes diagnostic imaging (X-rays), procedure and supply HCPCS codes, vaccine administration and blood draw services.

Payment comparisonFor these exceptions, payment is the lesser of billed charge or 100% of the applicable fee schedule (i.e., full fee-schedule amount).

Provider Reimbursement Actions

Billing Rule

Physician Extender Reimbursement Actions — Central Region (IN, KY, MO, OH, WI)

Physician Assistants (PA), Nurse Practitioners (NP) and Nurse Midwives (NM) are reimbursed based on the maximum allowable amount, which is the lesser of billed charges or a percentage of the amount listed in the Central Region applicable provider fee schedule. In Indiana, Kentucky, Missouri, Ohio, and Wisconsin the default reimbursement for PAs, NPs and NMs is the lesser of billed charges or 85% of the charge listed in the Central Region applicable physician fee schedule. Exceptions below are reimbursed at 100% of the Central Region applicable provider fee schedule when billed by physician extenders.

Applies to Physician Assistants (PA), Nurse Practitioners (NP), Nurse Midwives (NM) in Indiana, Kentucky, Missouri, Ohio, and Wisconsin
Default reimbursement: lesser of billed charge or 85% of Central Region applicable physician fee schedule
Exceptions reimbursed at 100% of Central Region applicable provider fee schedule: X-rays; all HCPCS codes; all supply codes; immunizations; blood draws
Maximum allowable amount includes member cost share (deductibles, copayments, coinsurance)

Key Definitions

Definition of physician extenders

DefinitionNon-physicians licensed or certified to perform services typically performed by a physician.

Included provider typesPhysician Assistants (PA), Nurse Practitioners (NP), Nurse Midwives (NM).

Role in policyServices performed by physician extenders are reimbursed according to the maximum allowable amount rules in this policy.

Definition of maximum allowable amount

DefinitionMaximum allowable amount is the lesser of billed charges or a percentage of the amount listed in the Central Region applicable provider fee schedule.

IncludesThe maximum allowable amount includes deductibles, copayments and coinsurance.

ApplicationUsed to determine reimbursement for physician extenders (standard rate 85% unless exception specifies 100%).