Reimbursement for Advanced Practice Providers (APPs)
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This policy governs reimbursement, billing, scope of practice, licensure, supervision, and payment rules for APRNs, DNPs, CNMs, CRNAs, and PAs providing services to University Health Alliance (UHA) members in Hawaii and through contracted entities.
No material clinical or coverage changes in this revision.
Overview and Definitions
APP Coverage Criteria
APP coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Valid, current, unrestricted state license for the State of Hawaii (required)
- Board certification for PAs by the NCCPA OR certification in the nursing specialty from a recognized national certifying body for APRNs (acceptable certifying bodies listed in policy)
- Appropriate employer credentialing/privileging for the services rendered
- Services provided within the APP's documented scope of practice and clinical experience; must consult, refer, or transfer care to a physician immediately when clinical circumstances dictate
ALL of the following
- Supervising physician is responsible to delineate duties and ensure those duties meet standards of medical necessity (not a cursory review)
- APRN or DNP not employed by a facility/physician that delineates scope is limited to services within formal training, specialty education/certification, and documented experience
- Independent APRNs/DNPs may be required to provide evidence/attestations of clinical proficiency and relevant training for requested clinical privileges
- Claims for PA/APRN billed independently may be denied if scope of service is incongruous with provider's level of training
Prohibited or restricted independent procedures (examples)
- Any body cavity procedures; anything deep to platysma; excision of likely lymph node; soft tissue lesion deep to fascia; lesions >5 cm; certain periorbital or scalp lesions (>2.5 cm)
- Any arterial procedures and venous procedures requiring exposure/possible exposure of saphenofemoral junction or ablation of greater/lesser saphenous or communicator vessels
- Any osseous or cartilaginous procedures, tendon/joint or other complex repairs beyond skin/subcutaneous/superficial fascia
- Any airway procedures, tube thoracostomy, or mechanical/non-invasive ventilatory management
- Any cardiac procedures, cardiac pacing, cardioversion, and central venous access
ALL of the following
- Claims must be submitted under the NPI of the provider who rendered the service unless 'incident to' or shared visit rules explicitly permit billing under a supervising physician's NPI
- APRN and PA services billed under their own NPI are reimbursed at 85% of the current UHA physician fee schedule (except as contractually allowed)
- When billing under the supervising physician's NPI ('incident to'), Medicare and UHA 'incident to' criteria must be met (outpatient office visits only; physician must have participated in key components, APP employed by physician/institution, initial visit by physician, physician physically present in same suite, physician active in ongoing care)
- Shared visit billing permitted in inpatient or hospital outpatient settings when the APP documents the service and the physician sees the patient the same day and attests concurrence; if the physician does not see the patient the same day, the service must be billed under the APP's NPI; inpatient consultations cannot be shared
ALL of the following
- Supervising physician must ensure compliance with state law and delineated duties; inadequate supervision may lead to denial of payment or be deemed professional misconduct
- For PAs practicing in Hawaii, the supervising physician must review all PA notes within seven days
Grounds for denial or limitation
- Practice outside the scope of experience or scope allowed by law/privileging
- Failure to comply with state laws or regulations
- Failure to refer when management exceeds scope
- Inappropriate ancillary testing, specialty referrals, or prescribing
- Failure to follow credentialing/privileging limits
Billing, NPI, and Reimbursement Rules
| Claims must be submitted under the name and National Provider Identifier (NPI) of the provider who actually rendered the service; APRN and PA services billed under their own NPI are reimbursed at 85% of the current UHA fee schedule for physicians (except as contractually allowed). 'Incident to' and shared visit billing under a physician NPI are permitted only when the specific criteria and limitations are met (see policy for outpatient 'incident to' and inpatient/shared visit conditions). |
Provider Billing Actions and Supervision Requirements
Incident to billing requirements (outpatient only)
Allow billing under the supervising physician's NPI using the 'incident to' provision only when all Medicare and UHA criteria are met for outpatient office visits. Requirements include physician participation in key components with an attestation of physical and meaningful participation, APP employment by the physician or institution, physician-performed initial visit for the condition, physician physically present in the same office suite and immediately available, and active ongoing physician involvement in the patient’s care. UHA may request documentation to retrospectively validate compliance and take corrective action for erroneous or fraudulent billing.
- 'Incident to' applies to outpatient office visits only.
- Physician must have participated personally in key components of evaluation and medical decision making and document an attestation of physical and meaningful participation.
- APP must be an employee of the physician or institution.
- Initial visit for any condition must be performed by the physician.
- Physician must be physically present in the same office suite and immediately available.
- Physician must play an active part in ongoing care; frequency of physician services should reflect continuing active participation.
- UHA may request documentation and take corrective action for erroneous or fraudulent billing.
Shared visit billing rules (inpatient/hospital outpatient)
Permit shared visit billing in hospital inpatient or hospital outpatient settings when an employed APP documents the service and the physician sees the patient the same day and attests concurrence; if the physician does not see the patient same day, bill under the APP's NPI. Inpatient consultations may not be shared.
- Shared visits apply to hospital inpatient or hospital outpatient settings only.
- If APP documents service and physician sees patient same day, physician may bill for the combined services.
- If physician does not see patient same day, bill under APRN/PA provider number.
- Inpatient consultations cannot be shared.
- Supervising hospital or ER physician must review and concur with APP notes and attach documentation to the APP note on the same date of service.
- Physician must document a written, signed attestation of active participation specifying the portion of the E/M visit performed.
Physician review and supervision timeframe (Hawaii PAs)
Supervising physicians must review all PA notes within seven days for PAs practicing in Hawaii, ensure oversight and compliance with applicable requirements, and understand that failure to provide required supervision may result in denial of payment and may be deemed professional misconduct.
- PAs in Hawaii must have physician review of all notes within seven days of the clinical encounter.
- Supervising physician must oversee compliance with statutory, regulatory, and medical staff standards.
- A physician who does not supervise APP services as required by state law may be deemed to have engaged in professional misconduct and payment for all services will be denied.
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