Mid-level Provider Reimbursement Policy
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This document governs reimbursement practices for mid-level providers (CNS, NP, PA) for covered medical and surgical services across all commercial lines of business and applies to network and non-network providers submitting UB-04 or CMS-1500 claims.
No material clinical or coverage changes in this revision.
Mid-level Provider Reimbursement Criteria
Mid-level provider reimbursement criteria
Covered when ALL of the following are met:
ALL of the following
- Service furnished by a mid-level provider (Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), or Physician Assistant (PA)).
- Claim submitted on UB-04 or CMS-1500 (or electronic equivalent).
- Provider bills using their individual National Provider Identifier (NPI).
- Service is a covered physician service (including evaluation & management [E/M] and surgical services).
- Reimbursement will be at 85% of the contracted physician rate for covered physician services provided by CNS/NP/PA.
Coding and claim submission notes
- Code claims according to industry-standard coding guidelines (AMA/CPT, HCPCS, DRG, CMS CCI edits) and document services accurately.
- Provider contract language may supersede this policy where applicable.
Coding and Reimbursement Details
| Claims should be coded according to AMA/CPT, HCPCS, DRG, and CMS coding guidelines including CCI edits. |
Billing and Reimbursement Rules for Providers
Billing and reimbursement rules for mid-level providers
Mid-level providers (CNS, NP, PA) must bill using their individual National Provider Identifier (NPI). WPS follows CMS guidelines and will reimburse these providers at 85% of the contracted physician rate for covered physician services, including evaluation & management (E/M) and surgical services.
- Bill all services using the individual provider's NPI.
- Reimbursement for covered physician services furnished by CNS/NP/PA is 85% of the contracted physician rate.
- Applies to E/M and surgical services considered physician services.
Key Definitions
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