ModifiedHighmark Blueshield NenyPolicy RP-068

Mid-Level Practitioners and Advanced Practice Providers

This policy governs reimbursement reductions and billing/credentialing requirements for services rendered by mid-level practitioners (e.g., PAs, NPs, CNSs, behavioral health therapists) to members in applicable commercial and Medicare Advantage markets served by the Plan.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMid-Level Practitioners and Advanced Practice Providers

Policy CodePolicy RP-068

Change TypeMaterial update — reimbursement grid and percentage changes

Effective DateSep 25, 2023

Next Review DateN/A

Key ActionDo not submit claims for a mid-level practitioner until the practitioner is enumerated and credentialed in the Plan's system to avoid claim rejection or post-payment recoupment.

SourceLink

POLICY UPDATE CHANGES

Updated to include regional specific grids and added specialties.

Changed LCSW reimbursement to 75%.

Added House Bill 1564 limitations on associate licenses.

85%mid-level typical reimbursement

75%behavioral health / associate reimbursement

100%commodity services reimbursed

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.

enumeration requirement

PA, DE, NY, WVapplicable markets

Mid-level Practitioner Reimbursement Criteria

Mid-level practitioner reimbursement criteria and billing rules

The Plan will consider reimbursement for mid-level practitioner services when all criteria are met:

Service is considered a physician's service and is a covered service under the member's benefit plan.

Service is within the Mid-level practitioner's scope of practice.

Services that traditionally have been reserved to physicians (e.g., physical examinations, minor surgery, setting casts for simple fractures, interpreting X-rays) are acceptable when they involve independent evaluation or treatment of the patient's condition.

Claims include the assigned individual Mid-level practitioner NPI and the Mid-level practitioner must be listed as the rendering provider on the claim.

If the Mid-level practitioner has not received confirmation of enumeration within the Plan's system, the claim will be rejected; failure to be enumerated may result in post-payment investigation and recoupment.

Commodity services (laboratory services, supplies, injected or infused drugs, diagnostic tests, after-hours services) billed on the same claim are reimbursed at 100% of the fee schedule allowance when covered and are not subject to mid-level reductions.

Providers with specific contract rates or providers contracted through a third‑party vendor are paid according to those contract rates, which supersede this policy direction.

Services rendered by Certified Registered Nurse Anesthetists (CRNA) do not apply to this policy.

Reimbursement eligibility criteria

The Plan will consider reimbursement for mid-level practitioner services when the following conditions are met:

Service is considered a physician-level service and is a covered service under the member's benefit plan.

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

Mid-level practitioner is enumerated and listed as the rendering provider NPI on the claim.

Commodity services (vaccines, drugs, labs, diagnostics, supplies, injected/infused drugs, diagnostic tests, after‑hours services) billed on the same claim are reimbursed at 100% and are excluded from mid-level reductions when covered.

ALL of the following

Examples of specified rates

Reimbursement eligibility criteria (APP-specific)

The Plan will consider reimbursement for APP-provided services when all criteria below are met.

Service is considered a physician's service and is a covered service under the member's benefit plan.

Service is within the Advanced Practice Provider's (APP) scope of practice.

Claims must include the individual Mid-level/APP NPI; the provider must be credentialed and enumerated in the Plan's system prior to claim submission.

If the APP has not received confirmation of enumeration within the Plan's system, the claim will be rejected.

Payment levels and regional adjustments

Reimbursement levels and special regional rules.

Certain services billed by an APP or Mid-level practitioner (laboratory services, supplies, injected/infused drugs, after‑hours services, diagnostic tests) are reimbursed at 100% of the fee schedule allowance when covered.

Mid-level reimbursement reductions apply as specified by practitioner type/specialty (examples include 85% and 75% of fee schedule for listed specialties).

Social Worker (grandfathered only) reimbursement where applicable is 65% of fee schedule; Master level therapists / LCSW reimbursement where applicable is 75% of fee schedule.

For New York region only (applicable to all products), mid-level reductions apply to provider unique pricing unless the provider's contract specifies otherwise.

The Plan follows standard CMS APP fee schedule reductions when processing Medicare Advantage claims.

Claim Submission and Reimbursement Levels

Claim submission requirementsmixed

NPI (individual mid-level rendering provider)

Claims must include assigned individual Mid-level practitioner NPI Number

Claim submission rulesmixed

Mid-level practitioner must be listed as rendering provider NPI on claims; commodity services billed on same claim (vaccines, drugs, labs, diagnostic tests, supplies, after-hours services) are reimbursed at 100% and are not subject to mid-level reductions.

Reduction rules by provider typemixed

No codes listed

inv-08: Reimbursement percentage thresholds

Primary reimbursement bandsMany mid-level practitioners are reimbursed at either 85% or 75% of the Plan fee schedule depending on specialty.

85% band examplesClinical Nurse Specialist (CNS), Clinical Registered Nurse Practitioner (CRNP), Physician Assistants (where allowed by law), Physician Assistant PCP, Licensed Clinical Social Workers (LCSW).

75% band examplesLicensed Associate Marriage and Family Therapist (LAMFT), Licensed Associate Professional Counselor (LAPC), Licensed Social Worker (LSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT).

inv-09: Reimbursement percentages

Regional/specialty variationCertain specialties and regions have specified reimbursement percentages (notably 85% and 75% of fee schedule); New York region has specific applicability notes.

Enumeration, Credentialing, and Claim Submission Actions

Prior Authorization

Enumeration and credentialing required

For credentialing and enumeration process and requirements, refer to the Provider Resource Center (Provider Manual, Chapter 3) for your location. Do NOT submit claims for services rendered by a Mid-Level practitioner or APP until that practitioner has been fully credentialed and enumerated in the Plan's system.

Failure to be enumerated/credentialed may result in post-payment investigation and recoupment of claim reimbursement.
If enumeration/credentialing is not confirmed by the Plan, the claim will be rejected; claims may be resubmitted once enumeration/credentialing is complete.

Denial Risk

Enumeration / Credentialing Requirement

If the APP/Mid-Level practitioner has not received confirmation from the Plan that enumeration within the Plan's system has been completed, the claim will be rejected. Ensure the practitioner is enumerated and credentialed before submitting claims to avoid denial or post-payment recovery.

Terms and Acronyms

inv-16: Defined practitioner types and credentialing/enumeration terms

APP (Advanced Practice Provider)Collective term for defined mid-level practitioners (e.g., CRNP, CNS, CNM, NP, PA).

Behavioral health associates & therapistsIncludes LAMFT, LAPC, LCSW, LSW, LMFT, LPC as defined practitioner types in policy definitions.

CredentialedSuccessfully completing verification of education, training, and professional experience to meet Plan requirements (inclusion in provider directory).

EnumeratedAssignment of a specific identifying number (Blue Shield ID) to a provider for submission on claims.

inv-17: Credentialed / Enumerated

Credentialed (definition)Verification that a provider's education, training, and professional experience meet the Plan's internal requirements; credentialed providers are included in the provider directory.

Policy Summary

PayerHighmark Blueshield Neny

PolicyMid-Level Practitioners and Advanced Practice Providers

Policy CodePolicy RP-068

Change TypeMaterial update — reimbursement grid and percentage changes

Effective DateSep 25, 2023

Next Review DateN/A

Key ActionDo not submit claims for a mid-level practitioner until the practitioner is enumerated and credentialed in the Plan's system to avoid claim rejection or post-payment recoupment.

SourceLink

On This Page

Reimbursed at 85% of fee schedule: Clinical Nurse Specialist (CNS), Certified Registered Nurse Practitioner (CRNP), Physician Assistants (where allowed by law), Physician Assistant PCP, certain LCSWs/behavioral health specialties.

Reimbursed at 75% of fee schedule: Licensed Associate Marriage and Family Therapist (LAMFT), Licensed Associate Professional Counselor (LAPC), Licensed Social Worker (LSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT).

Certain Mid-level practitioners may be aggregated into attributed identifiers in Plan systems; confirm specialty via Provider Data Maintenance (Availity).

Mid-level practitioner reimbursement reductions apply to professional claims (UB/1500) for enumerated/credentialed practitioners; commodity services on the same claim are excluded from reductions.

Services rendered by Certified Registered Nurse Anesthetists (CRNA) are excluded from this policy.

85% specialty listCNS (including Mental Health), CRNP (including PCP and Mental Health), Physician Assistants (where allowed by law) and select LCSWs are listed at 85% when applicable.

75% specialty listLAMFT, LAPC, LSW, LPC, LMFT are listed at 75% when applicable.

inv-10: Social worker reimbursement percentage (grandfathered)

Grandfathered social worker rateSocial Worker (grandfathered only) reimbursed at 65% of the fee schedule for Commercial and Medicare Advantage where applicable.

Applicability noteAsterisk denotes not applicable to New York region; Pennsylvania grandfathering rules referenced for legacy license types.

Products referencedCommercial and Medicare Advantage reductions specified in policy text.

inv-11: Master level therapists / LCSW reimbursement percentage

LCSW / Master-level therapist rateLicensed Clinical Social Workers (LCSWs) and master-level therapists are reimbursed at 75% of the Plan fee schedule where indicated.

ScopeApplies to listed master-level therapist types unless regional or contract-specific rules supersede.

ExceptionNew York region and provider contract terms may alter applicability per policy notes.

Claims without confirmed enumeration are subject to rejection and/or recoupment.
Confirm specialty and practitioner details via the Provider Data Maintenance application (Availity) as needed.

Billing Rule

Provider claim requirements

Claims must include the assigned individual Mid‑Level practitioner NPI. Mid‑Level providers and APPs must be credentialed and enumerated in the Plan's system for reimbursement to be considered. Services must be within the practitioner’s scope of practice and be covered under the member’s benefit plan.

Include the individual Mid‑Level practitioner NPI on professional claims.
Ensure the APP/Mid‑Level practitioner is credentialed and enumerated prior to billing.
Services traditionally reserved to physicians may be considered when within scope and covered by the plan.

Denial Risk

Enumeration requirement

If an APP's enumeration in the Plan's system cannot be confirmed, the claim will be rejected. Reimbursement reductions and regional rules (for example, New York region mid‑level reductions to provider unique pricing) may apply even for enumerated/credentialed APPs per contract terms.

Unconfirmed APP enumeration will cause claim rejection.
Contract-specific rates and third‑party vendor arrangements may supersede these policy directions.
CRNAs and certain contracted arrangements are excluded from these reductions.

Enumerated (definition)Assignment of a specific identifying number (Blue Shield ID) to a provider for claim submission; required for claims processing.

Operational distinctionCredentialing is a verification process for in-network status; enumeration assigns the claim-submittable identifier used on claims.

inv-18: Enumerated

Enumerated meaningThe assignment of a specific identifying number (Blue Shield ID) to a provider for submission on claims.

Claim requirementEnumerated identifier must be listed as the rendering provider on claims where the mid-level performs the service.

Rejection riskClaims submitted prior to confirmed enumeration may be rejected or subject to post-payment recoupment.

inv-19: Credentialed

Credentialed meaningSuccessfully completing the process of having education, training, and professional experience verified to meet the Plan's internal requirements for serving as an in-network provider.

Provider directoryCredentialed providers are included in the provider directory per policy definitions.

Prerequisite for reimbursementCredentialing is required (alongside enumeration) for certain APP claim acceptance and to avoid denial risk.

inv-20: Acronyms

APPAdvanced Practice Provider.

APNAdvanced Practice Nurse.

CNPCertified Nurse Practitioner.

CNSClinical Nurse Specialist.

CRNACertified Registered Nurse Anesthetist.

inv-21: APP

APPAdvanced Practice Provider.

UsageUsed throughout policy to reference non-physician mid-level providers subject to reimbursement rules.

IncludesExamples include CRNP, CNS, CNM, NP, PA per definitions.

inv-22: CMS

CMSCenters for Medicare and Medicaid Services.

Policy alignmentPolicy follows standard CMS APP fee schedule reductions for Medicare Advantage claim processing as noted in the document.

ContextReferenced to explain MA claim processing conventions.

inv-23: CNM

CNMCertified Nurse Midwife.

Applicability noteCNMs are listed among defined mid-level practitioner types; New York region applicability varies per policy grids.

ClaimingIf enumerated/credentialed, CNM services follow the general reimbursement rules unless excluded.

inv-24: CNS

CNSClinical Nurse Specialist.

Role in reimbursement bandsCNS (including Mental Health CNS) appears in the 85% reimbursement band in policy examples.

In-network requirementsMust be credentialed and enumerated per policy to avoid claim rejection.

inv-25: CRNA

CRNACertified Registered Nurse Anesthetist.

ExclusionServices rendered by CRNAs do not apply to this mid-level reimbursement reduction policy.

ReferenceAssistant-at-surgery payment follows RP-001 rules; CRNAs excluded from this policy direction.

inv-26: Credentialed

Plan-specific credentialed definitionCredentialed = Successfully completing verification of education, training, and professional experience to meet the internal requirements of the Plan; credentialed providers are included in the provider directory.

Operational impactCredentialing is required before in-network listing and may be required for claim acceptance alongside enumeration.

Related actionsSee Provider Resource/Provider Services for credentialing process details referenced in policy.

inv-27: Enumerated

Plan-specific enumerated definitionEnumerated = Assignment of a specific identifying number (Blue Shield ID) to a provider for submission on claims.

Claims requirementEnumerated identifier must be listed as the rendering provider on claims where the mid-level performs the service; failure to confirm enumeration may result in claim rejection or recoupment.

Resubmission optionIf claim rejected for lack of enumeration, claim may be resubmitted after enumeration is completed per policy guidance.