CurrentBlue Cross Blue Shield - WisconsinPolicy C-20001

Nurse Practitioner and Physician Assistant Services Professional Reimbursement Policy

Defines BCBSWI reimbursement stance for services provided by nurse practitioners (NPs) and physician assistants (PAs), including when payment reductions apply and billing expectations; applies to commercial lines governed by the policy. Affects providers submitting professional claims for NP/PA services and BCBSWI administration of those claims.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyNurse Practitioner and Physician Assistant Services Professional Reimbursement Policy

Policy CodePolicy C-20001

Change TypeMaterial updates (state exemptions and payment reduction clarifications)

Effective DateFeb 1, 2025

Next Review Date

Key ActionSubmit NP/PA professional services with the NP/PA's own NPI and ensure services meet authorization and medical necessity guidelines with appropriate CPT/HCPCS/revenue codes.

SourceLink

POLICY UPDATE CHANGES

Added Colorado and Ohio exemptions.

Clarified services not eligible for payment reduction and removed Preventive and Radiology services from the not-applicable list; added Kentucky and Wisconsin exemptions.

Added Nevada exemption effective 03/01/2025.

1policy governing NP/PA reimbursement

02/01/2025policy effective date

03/12/2025last approval/review date

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.

NP/PA Reimbursement Coverage Criteria

NP/PA reimbursement criteria

Reimbursement is allowed when the following criteria are met:

ALL of the following

Service is within the NP or PA provider's scope of practice
Service is considered a physician's service
Payment reduction consistent with CMS reimbursement may be applied unless exempted

ALL of the following

Not subject to payment reduction (service types)
- Durable Medical Equipment; Prosthetics, Orthotics and Supplies (DMEPOS)
- Drugs
- Laboratory services and laboratory screening tests
State-specific exemptions
- Colorado — reimburses NPs and PAs using the applicable established fee schedule (exempt)
- Kentucky — reimburses NPs and PAs using the applicable established fee schedule (exempt)
- Maine — does not apply a payment reduction to Nurse Practitioner services (exempt)
- Nevada — reimburses NPs and PAs using the applicable established fee schedule (exempt)
- New Hampshire — market is not subject to this policy (exempt)
- Ohio — does not apply a payment reduction to Radiology services (partial exemption)

ALL of the following

Services furnished by the NP or PA should be submitted with their own NPI as the rendering provider
Standard correct coding and applicable authorization/medical necessity requirements apply

Codes, Payment Reductions, and Applicability

Codes with specified payment reduction treatment in certain marketsmixed

OOO1F-36410, 36430-69990, 90749, 90752-99607

Codes to which Anthem Blue Cross and Blue Shield (specific markets) only applies a payment reduction (listed in policy).

Payment reduction applicability — exceptions and service types not subject to reduction

Payment reduction rulePayment reductions are applied consistent with CMS reimbursement unless exempted by the policy or state-specific rules.

Services not subject to reductionDurable Medical Equipment; Prosthetics, Orthotics and Supplies (DMEPOS); Drugs; Laboratory Services and Laboratory Screening Tests.

State-specific exemptionsCertain states are exempt or have alternate rules (examples listed include Colorado, Georgia, Kentucky, Maine, Nevada, New Hampshire, Ohio, Wisconsin).

WI-specific treatmentWisconsin: reduction applies only to codes OOO1F-36410, 36430-69990, 90749, 90752-99607.

Authorization, Documentation, and Provider Requirements

Prior Authorization

Authorization, medical necessity, and documentation requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence. Use appropriate billing and submission guidelines with industry-standard CPT/HCPCS/revenue codes; claims must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in recovery/recoupment of payment or claim rejection/denial.

Obtain any required prior authorization and ensure services meet medical necessity for the procedure and diagnosis in the member's state.
Bill using correct CPT, HCPCS, and/or revenue codes and submit documentation that fully supports the billed services in the medical record or office notes.
Be aware that noncompliance with coding/billing guidelines or policy may lead to payment recovery/recoupment or claim denial.

Billing, Provider Identification, and Reimbursement Definitions

Billing and provider identification — required claim elements and NP/PA submission expectations

Required claim codesServices must be billed with CPT, HCPCS and/or revenue codes and fully supported in the medical record or office notes.

Rendering provider identificationServices furnished by the NP or PA should be submitted with the NP/PA's own NPI as the rendering provider.

Documentation standardClaims must be supported by appropriate medical record documentation and meet authorization and medical necessity guidelines.

Reimbursement criteria — scope of practice and service categories not eligible for physician-equivalent reimbursement

Scope of practice requirementService must be within the NP or PA provider's scope of practice to qualify for reimbursement.

Physician-equivalent services