In order to align with the Centers for Medicare & Medicaid Services (CMS) and industry standards for “incident to” billing practices, AmeriHealth will be updating its policy on reimbursing certified registered nurse practitioners (CRNP) and physician assistants (PA). Claim Payment Policy: #00.10.40c: Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs) was posted as a Notification on March 1, 2019, and will go into effect June 1, 2019.

Policy updates

AmeriHealth will update its policy related to the reimbursement and billing guidelines for CRNPs and PAs as follows:

• “Incident to” services will be paid at 100 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement.
  • For “incident to” services performed by a CRNP or PA, the supervising physician should bill using their own National Provider Identifier (NPI) and report Modifier SA.
• “Non-incident to” services will be paid at 85 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement that covers the CRNP or PA.
  • “Non-incident to” services should be billed using the NPI number of the CRNP or PA who performed the service, rather than a physician’s.

Note: Covered vaccines and injectables are eligible for reimbursement consideration by AmeriHealth at 100 percent of the standard vaccine and injectable fee schedule.

Exclusions

There are certain specialties to which this policy does not apply, including hospital-based specialties (e.g., hospitalist, emergency medicine) and urgent care practices.

For more information

To view the Notification for the expanded policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Active Notifications.

For further questions on “incident to” billing and becoming a credentialed CRNP or PA, please review our Updated credentialing requirements and reimbursement position for CRNPs and PAs (FAQ), which can also be found in the Frequently Asked Questions archive on AmeriHealth NaviNet^® Plan Central or in the Quick Links menu on the right-hand side of this page. Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please email us at incidentto@amerihealth.com. Please be sure to your name, contact number, and provider ID in your email. 

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