CurrentEmpire BluecrossPolicy C-20001

Nurse Practitioner and Physician Assistant Services Professional reimbursement

Governs reimbursement rules for services provided by Nurse Practitioners (NPs) and Physician Assistants (PAs) under Empire Bluecross commercial plans; applies when services are within scope of practice and meet plan/contract requirements.

Policy Summary

PayerEmpire Bluecross

PolicyNurse Practitioner and Physician Assistant Services Professional reimbursement

Policy CodePolicy C-20001

Change TypeClarification and state exemptions added

Effective DateFeb 1, 2025

Next Review DateN/A

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence.

SourceLink

POLICY UPDATE CHANGES

Clarified services not eligible for payment reduction to a stand-alone statement and removed Preventive and Radiology services.

Added Kentucky and Wisconsin exemptions.

Effective dates added for Nevada and Maine.

3examples of excluded categories

Multiplestate-specific exemptions

Standardcoding requirement

Rendering NPIbilling requirement

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Reimbursement and Coverage Criteria

Reimbursement criteria

The Health Plan allows reimbursement for services provided by NPs and PAs when the following conditions are met:

ALL of the following

The service is within the NP or PA provider's scope of practice.
The service is considered a physician's service.
A payment reduction consistent with CMS reimbursement is applied, except for service categories excluded from payment reduction (see Exclusions and exemptions).
Services furnished by the NP or PA should be submitted with their own NPI as the rendering provider.

Conditions for reimbursement

Required conditions

ALL of the following

Service is within the NP or PA provider's scope of practice.
Service is considered a physician's service.
A payment reduction consistent with CMS reimbursement is applied.

Billing and documentation

Billing requirements

ALL of the following

Services furnished by the NP or PA should be submitted with their own NPI as the rendering provider.
Claims must use industry-standard CPT, HCPCS, and/or revenue codes; codes must be fully supported in the medical record and/or office notes.
Standard correct coding applies. Failure to follow appropriate coding/billing guidelines may result in recoupment, rejection, or denial of the claim.

Billing Codes and Coding Requirements

Billing codesmixed

CPT/HCPCS/Revenue

Claims must use industry standard CPT, HCPCS, and/or revenue codes supported by the medical record.

Correct coding requirement

RequirementStandard correct coding applies for all claims (use industry-standard CPT, HCPCS, and/or revenue codes supported by the medical record).

ConsequenceFailure to follow correct coding may result in recoupment, rejection, or denial as noted in billing requirements.

ScopeApplies to services billed by Nurse Practitioners (NPs) and Physician Assistants (PAs) under this policy.

Authorization, Medical Necessity, and Provider Responsibilities

Prior Authorization

Authorization and medical necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence. Follow proper billing and submission guidelines, using industry-standard CPT, HCPCS, or revenue codes fully supported by the medical record; failure to follow authorization, medical necessity, or billing requirements may result in recoupment, rejection, or denial of payment.

Obtain any required prior authorization consistent with the procedure, diagnosis, and the member’s state of residence.
Submit claims using compliant CPT, HCPCS, and/or revenue codes that are fully supported by medical records and office notes.
Be aware that failure to follow coding/billing or authorization requirements may lead to recovery/recoupment, claim rejection, or denial.

Definitions

General Reimbursement Policy Definitions

Definitions referenceGeneral Reimbursement Policy Definitions (see Definitions section of the policy).

Policy scopeDefines terminology used throughout the NP/PA reimbursement policy to ensure consistent application of coverage and billing rules.

UsageTerms align with standard reimbursement and billing language used by the Health Plan and CMS-consistent payment policies.