CurrentBlue Cross Blue Shield - WisconsinPolicy C-11002

Incident to Services and Billing

Defines Anthem Blue Cross and Blue Shield - Wisconsin reimbursement and billing rules for 'Incident to' professional services, including when services billed under a supervising provider are eligible for reduced reimbursement and which providers/services are ineligible. Affects providers submitting professional claims to the Health Plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyIncident to Services and Billing

Policy CodePolicy C-11002

Change TypeOperational updatesadded exemptions

Effective DateOct 1, 2024

Next Review DateN/A

Key ActionSupervising provider must remain actively involved, be physically present in the office suite or immediately available via interactive communication, and document review of each service provided by NPP or auxiliary personnel.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy content to separate Incident to services from Incident to billing guidelines and updated definitions and modifier guidance.

Added exemptions for Colorado, Georgia, Nevada, and New Hampshire exempting the payment reduction and SA modifier requirement.

15%Reimbursement reduction

SAModifier required

4Exempt states

NP, PANPP examples

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyIncident to Services and Billing

Policy CodePolicy C-11002

Change TypeOperational updatesadded exemptions

Effective DateOct 1, 2024

Next Review DateN/A

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.

Incident to Billing: Eligibility and Exclusions

Incident to billing eligibility and exclusions

Covered when ALL of the following conditions are met:

Incident to services billed in accordance with this policy are eligible for reimbursement under the supervising provider's NPI with a 15% reduction to the supervising provider's maximum allowance.

The Health Plan does not follow CMS Incident to reimbursement rules for any physician or Non-Physician Practitioner (NPP) who has been assigned or is waiting for their own NPI; providers with an NPI and recognized by the Health Plan as eligible to submit claims must bill under their own NPI.

The rendering clinician must be ineligible to submit claims directly to the Health Plan (for example, qualified auxiliary office personnel or an NPP not yet eligible to bill independently); services rendered by any provider who is eligible to directly submit claims to the Health Plan are excluded from Incident to reimbursement.

The supervising (billing) provider must remain actively involved in ongoing care, be physically present in the office suite or immediately available via interactive communication as needed during the evaluation and management visit or other rendered service, and must document review of each service provided by the NPP or auxiliary personnel.

Modifier SA must be appended to all claim submissions identifying non-surgical Incident to billing when the supervising physician bills for NPP services (subject to state exemptions noted below).

Excluded or Bundled Services

Services that are essential to the performance of a professional service are considered bundled and are not eligible for separate reimbursement.
Services identified with PCITC Indicator 5 are considered Incident to and are not allowed for reimbursement when billed by a professional provider in a facility setting.

Explicit exclusions

Services provided by ambulance or Emergency Medical Technicians (EMT) performed under telephonic supervision are not eligible for Incident to billing.
Services performed by non-licensed health care providers who do not qualify as auxiliary personnel are not eligible for Incident to billing.
When a provider type is eligible to receive an NPI and is recognized by the Health Plan to submit claims directly, their services are not eligible for Incident to reimbursement while they are waiting to receive their NPI and/or Health Plan eligibility.

State exemptions: Colorado, Georgia, Nevada, and New Hampshire are exempt from the 15% payment reduction and do not require the SA modifier for non-surgical Incident to billing.

Modifier and Reimbursement Adjustment Rules

Incident to related modifierModifier

SA	Modifier appended when supervising physician bills on behalf of Non-Physician Practitioner for non-surgical services

Reimbursement adjustment — Incident to billing

Adjustment15% reduction of the supervising provider's maximum allowance when services are billed as Incident to under the supervising provider's NPI.

Applies whenRendering NPP or qualified auxiliary office personnel are ineligible to submit claims directly to the Health Plan and services are billed under the supervising provider's NPI.

ExemptionsDoes not apply in states specifically exempted by the policy (see exemptions list).

Source policy noteThe Health Plan does not follow CMS Incident to reimbursement rules for any physician or NPP who has been assigned or is waiting for their own NPI.

Supervision and Eligibility Requirements — Provider Responsibilities

Billing Rule

Supervising provider presence, involvement, and billing eligibility

The supervising provider must remain actively involved in the member's ongoing care, be physically present in the office suite or immediately available (including via interactive communication when necessary), and must document in the medical record that they reviewed the documentation for each service performed by the NPP or auxiliary personnel. Services rendered by any provider who is eligible to directly submit claims to the Health Plan are not eligible for Incident to reimbursement.

Supervising provider must stay involved and have an active part in ongoing care; be physically present in the office suite and/or immediately available via interactive communication.
Supervising provider must document review of the medical record for each service the NPP or auxiliary personnel was involved with.
Any provider eligible to submit claims directly to the Health Plan must bill under their own NPI and their services are not eligible for Incident to reimbursement.

Key Terms

Auxiliary personnel

DefinitionPersonnel who are not eligible to directly submit claims to the Health Plan and therefore are not eligible to receive direct reimbursement.

DeterminationEligibility to submit claims is determined by the Health Plan; those deemed ineligible are considered auxiliary personnel under this policy.

Billing impactServices rendered by auxiliary personnel may be billed under a supervising provider's NPI when criteria for Incident to billing are met.

Incident to Services

DefinitionServices or supplies integral to a physician's service and services rendered by NPPs or qualified auxiliary office personnel billed under the supervising provider's NPI.

Billing ruleWhen billed in accordance with this policy, Incident to services are eligible for reimbursement under the supervising provider's NPI with the applicable reimbursement adjustment.