CurrentEmblemHealthPolicy RP20210011

Mid-Level Practitioner Reimbursement Policy (Commercial)

Defines how EmblemHealth reimburses services provided by mid-level (non-physician) practitioners (e.g., PAs, NPs, CNSs) for commercial products, and the billing/credentialing requirements that apply to in-network and out-of-network providers.

Policy Summary

PayerEmblemHealth

PolicyMid-Level Practitioner Reimbursement Policy (Commercial)

Policy CodePolicy RP20210011

Change TypeAdministrative/template revision (no material clinical or coverage changes)

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionEnsure mid-level practitioners are credentialed and include the individual mid-level practitioner's NPI on claims to receive reimbursement.

SourceLink

POLICY UPDATE CHANGES

Reformatted and reorganized policy, transferred content to new template with new Reimbursement Policy Number.

85%reimbursement rate vs physician

15%reduction from physician fee

100%incident-to reimbursement

In‑network & Out‑of‑networknetwork applicability

Reimbursement Criteria for Mid-Level Practitioners

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Reimbursement criteria for mid-level practitioners

EmblemHealth reimburses mid-level practitioner services under the following conditions and distinctions:

Services considered physicians' services and covered under the member's benefit plan are eligible for reimbursement at 85% of the applicable fee schedule.

Service is within the mid-level practitioner's state‑licensed scope of practice.

Claims must include the assigned individual mid-level practitioner NPI number and the mid-level practitioner must be credentialed.

See EmblemHealth credentialing resources for details.

Policy applies to services provided by mid-level providers within a medical or other healthcare practice and applies to both in‑network and out‑of‑network providers.

EmblemHealth recognizes licensed mid-level practitioners as a separate provider type when working under the supervision of a participating physician.

ALL of the following

The mid-level practitioner is ineligible for their own NPI number.
Services are an integral (incidental) part of the physician's services and commonly rendered without charge or included in the physician's bill.
Services are provided in the office or clinic setting (does not apply in hospital inpatient or outpatient settings).
The physician personally treated the patient on the initial visit for the particular medical problem and established the diagnosis and treatment plan.
Services are provided under direct physician supervision (supervising physician must be present in the location of service and immediately available to provide assistance and direction).
The supervising physician has ongoing participation in the patient's care and that involvement is documented in the medical record.

Consistent with CMS guidance, reimbursement at 85% applies regardless of the location where services are provided (except incident-to 100% conditions as specified).

Coding and Reimbursement Details

Coding guidancemixed

EmblemHealth follows CPT and CMS coding guidance and industry-standard claims editing; failure to follow may result in denial or recoupment.

inv-03: Reimbursement rate — 85% of applicable fee schedule

Reimbursement rate85% of the applicable fee schedule (15% reduction from physician fee schedule)

ApplicabilityApplies regardless of service location; applies to both in‑network and out‑of‑network providers as stated in policy scope

Condition for service typeOnly services considered physicians' services and covered under the member's benefit plan are eligible

Documentation requirementClaims must include the individual mid‑level practitioner's assigned NPI number

Credentialing, Billing, and Incident-to Requirements

Billing Rule

Credentialing and NPI billing required

Mid-level practitioners must be credentialed with EmblemHealth and claims must include the assigned individual mid-level practitioner NPI number. Failure to submit the individual practitioner's NPI or to complete credentialing may affect reimbursement (services reimbursed at 85% of the applicable fee schedule).

Claims must include assigned individual Mid-Level practitioner NPI Number
Mid-Level Providers must be credentialed
Reimbursement is generally 85% of the applicable fee schedule

Prior Authorization

Conditions for 100% incident-to reimbursement

Incident-to services are reimbursed at 100% only when the mid-level practitioner is ineligible for their own NPI and every incident-to criterion is met; otherwise standard mid-level reimbursement applies.

Services must be an integral part of the physician's services and commonly rendered without separate charge
Applies only in the office or clinic (not inpatient/outpatient hospital)
Physician must have personally treated the patient on the initial visit and established the diagnosis and treatment plan
Services must be provided under direct physician supervision with the supervising physician present in the location and immediately available
Physician must have ongoing participation in the patient’s care, documented in the medical record
Services meeting incident-to criteria should be reported under the supervising physician's NPI

Definitions

inv-06: Mid-Level Practitioner — define the term and list included provider types

DefinitionAn advanced practice health care provider, other than a physician, licensed by the state to assist or act in place of a physician; may bill directly under applicable state law

Included provider typesPhysician Assistants (PA), Nurse Practitioners (NP), Clinical Nurse Specialists (CNS)

Scope requirementServices must be within the mid‑level practitioner's state‑licensed scope of practice

CredentialingMid‑level practitioners must be credentialed for reimbursement eligibility