Currentpriority healthPolicy N/A

Advanced Practice Professional (APP) billing and payment

Governs billing and reimbursement rules for services rendered by Advanced Practice Providers (APPs) including PAs, NPs, CNS, APRN, and CNM and explains direct billing, incident-to, split/shared, multi-specialty group reporting, and reimbursement rates applicable to Priority Health plans.

Policy Summary

Payerpriority health

PolicyAdvanced Practice Professional (APP) billing and payment

Policy CodePolicy N/A

Change TypeAdded guidance for multi-specialty group reporting (CMS alignment)

Effective DateNov 11, 2024

Next Review DateFeb 1, 2025

Key ActionAPPs should bill directly using their own name and NPI for services they are licensed to provide and follow incident-to and multi-specialty claim reporting rules as applicable.

SourceLink

POLICY UPDATE CHANGES

Added the section on 'APPs in Multi-Specialty Groups' aligning with updated CMS billing requirements effective Dec. 1, 2024.

85%standard reimbursement of APP services relative to physician fee schedule

100%reimbursement when billed as incident-to or specified services

Dec. 1, 2024CMS change effective

Medicaid exemptMedicaid exemption

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.

Coverage Criteria for APP Services

Coverage criteria for APP services

Covered when the following conditions for each billing scenario are met:

ALL of the following

APP is licensed to provide the service under state and federal law (may initiate and change plan of care).
APP provides the entire service to the member (may perform services for new or established patients, office visits, procedures, ER and critical care as within scope).
Service is billed under the APP's own name and NPI.
Reimbursement: most services reimbursed at 85% of the physician fee schedule (Medicaid exempt).

ALL of the following

Physician performed an initial service and established a plan of care on a prior date.
APP provides the service in its entirety to an established patient for continuation of that plan of care and is not treating a new problem.
Supervising physician must be actively participating in the patient's care and must be present in the office supervising the APP (services must be performed in the office setting).
APP must be employed by the physician practice (contracted, full- or part-time).
Claim requirements: services billed under the physician's name and NPI; supervising physician and NPI must be listed on the claim; SA modifier is required when reporting as 'incident to'.
Reimbursement: incident-to services reimbursed at 100% of the physician fee schedule when all requirements are met and CMS guidance is followed.

ALL of the following

When services qualify as split/shared between a physician and an APP, follow shared or split billing guidelines.
For hospital-employed APPs, physician documentation — not APP documentation alone — should determine visit level; do not 'split' bill to inappropriately attribute level based solely on APP documentation.

ALL of the following

ONE of
- Anesthesia
- Laboratory services, including venipuncture and radiology
- Immunizations, vaccines and toxoids
- Injectables, supplies and ancillary services
- Services by APPs credentialed as Primary Care providers
- Services by APPs credentialed as Certified Nurse Midwives (CNMs)

ALL of the following

Services performed outside the APP's scope of practice or contrary to state/federal regulations will be denied.
Unlicensed clinicians, auxiliary staff, registered nurses, and medical assistants are not considered APPs for billing under this policy.

Coding and Reimbursement Rules

Multi-specialty reportingmixed

specialty 2-digit

Use both the 2-digit specialty code and description on claim when APP specialty differs

Reimbursement thresholds

Standard APP reimbursementMost APP services reimbursed at 85% of the physician fee schedule.

Incident-to / specified servicesServices billed under a supervising physician as 'incident to' are reimbursed at 100% of the physician fee schedule.

Medicaid exemptionMedicaid is exempt from the 85% mid-level (APP) reduction.

Scope for 100% exceptionsCertain contracted services (e.g., anesthesia, labs, immunizations, injectables, ancillary services, APPs credentialed as PCPs or CNMs) may be paid at 100% when specified by contract.

Billing and Provider Action Requirements

Billing Rule

Direct billing guidance — APPs bill under their own name/NPI

APPs should bill directly for services they're licensed to provide under state and federal law. These services must be billed under the APP's own name and NPI. Direct billing applies when the APP provides the entire service to the member, including initiating and changing the plan of care without physician oversight. APPs may provide services to new or established members for routine, new, or existing problems and may perform office visits, office procedures, or other services defined within their scope of practice under applicable state law. Services may be provided in office or hospital settings, including emergency department and critical care settings. A supervising physician does not need to be in the office suite for direct-billed office visits. Reimbursement for directly billed APP services is at 85% of the physician fee schedule.

APP bills using their own name and NPI
Reimbursement = 85% of physician fee schedule
APP may initiate and change plan of care without physician oversight
Applicable to new or established patients and to services within APP scope of practice
Applies in office and hospital settings, including ER/critical care

Definitions and Billing Scenarios

Definition: Advanced Practice Provider (APP)

Included APP typesPhysician Assistants (PA), Nurse Practitioners (NP), Clinical Nurse Specialists (CNS), Advanced Practice Registered Nurse (APRN), Certified Nurse Midwives (CNM).

Excludes unlicensed/auxiliary staffRegistered nurses, certified scrub techs, medical assistants, certified surgical assistants, certified registered nurse assistants and other auxiliary unlicensed staff aren't classified as APP.

Licensure requirementAPPs must be licensed by the state in which they provide health care services and operate in accordance with state and federal laws.

Definition: Incident-to services (operational notes)

Billing under physician for incident-toAPPs reporting services as 'incident to' must bill under the supervising physician's name and NPI and include the supervising physician and NPI on the claim.

Policy Summary

Payerpriority health

PolicyAdvanced Practice Professional (APP) billing and payment

Policy CodePolicy N/A

Change TypeAdded guidance for multi-specialty group reporting (CMS alignment)

Effective DateNov 11, 2024

Next Review DateFeb 1, 2025

Key ActionAPPs should bill directly using their own name and NPI for services they are licensed to provide and follow incident-to and multi-specialty claim reporting rules as applicable.

SourceLink

On This Page

Documentation Required

Incident-to billing requirements

When APP services are reported as 'incident to' a physician's service, the service must meet CMS 'incident to' requirements and be billed under the physician's name and NPI. Key requirements: the physician must have performed an initial service and established a plan of care on a prior date; the APP must provide services in accordance with that plan; services must be for established patients and not for new problems; the supervising physician must be actively participating in the patient’s care (e.g., available at regular intervals and involved with changes in the care plan); the APP must be employed by or contracted with the physician practice; services must be furnished in the office setting with the supervising physician onsite in the office suite; the supervising physician and NPI must be listed on the claim; and the SA modifier is required when reporting APP services as 'incident to'. The physician's signature alone does not satisfy incident-to requirements. Priority Health aligns to CMS incident-to rules.

Reimbursement = 100% of physician fee schedule when billed as incident-to
Physician must have performed an initial visit and established a plan of care prior to APP visits
APP may only treat established patients and not new problems under incident-to
Supervising physician must be actively participating and be onsite in the office setting
APP must be employed by or contracted with the physician practice
Supervising physician name and NPI must be on the claim
Use SA modifier for incident-to APP billing

Note

Multi-specialty group claim reporting (Medicare)

For APPs practicing in multi-specialty groups (Medicare effective Dec 1, 2024), provide additional claim-level information when the APP’s specialty differs from the diagnosis or when separate payment consideration may apply. Indicate the APP specialty on the claim using both the 2-digit specialty code and the specialty description. For paper CMS-1500 claims, place the specialty information in Item 19. For electronic 837P claims, use the Loop 2300 NTE segment or the line NTE in Loop 2400 (837P). This supports separate Medicare payment consideration when evaluation and management services are furnished by a different specialty for separate clinical conditions.

Include 2-digit specialty code AND specialty description
Paper claims: Item 19 on CMS-1500
Electronic claims: Loop 2300 NTE or line NTE in Loop 2400 (837P)
Indicate specialty when diagnosis differs from APP specialty or when separate payment may apply

Patient and service conditions

Physician must have performed an initial service and established a plan of care prior to the APP visit; APP may provide the service only to established patients for continuation of that plan and may not treat new problems.

Supervision and settingServices must be provided in the office setting with the supervising physician physically present in the office suite and actively participating in the patient's care; APP must be employed by the physician practice as contracted.

Modifier requirementSA modifier is required when APP services are reported as 'incident to'.

Definition: Split/shared services (operational notes)

When split/shared appliesFollow shared or split billing guidelines when both an APP and physician perform services that meet split/shared criteria.

Hospital-employed APPsWhen a physician and a hospital-employed APP perform a shared visit, the physician must use their own documentation to determine the level of service; APP documentation cannot be used to determine physician level.

Billing provider determinationReference Priority Health's shared or split billing guidelines for the appropriate billing provider and adhere to contracted rates, member benefits, clinical edits, and authorization requirements.