AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth) and AmeriHealth Administrators have updated their reimbursement guidelines and credentialing requirements for Advanced Practice Providers (APPs), which are Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs).
Credentialing
An APP must meet all the requirements of our credentialing and contracting criteria to be eligible for reimbursement for the medically necessary services they provide.
We will credential CRNPs working in blended practice arrangements with physicians, as well as CRNP-only primary care practices or behavioral health practices. CRNPs working in CRNP-only medical specialty practices will only be credentialed if they are board-certified by one of the following organizations in the specialty in which they practice:
- American Academy of Nurse Practitioners Certification Board (AANPCB)
- American Association of Critical Care Nurses (AACN)
- American Nurses Credentialing Center (ANCC)
- National Certification Corporation (NCC)
- Pediatric Certification Nursing Board (PCNB)
We only credential PAs working in blended practice arrangements with physicians.
Reimbursement
- Outpatient/Office setting: APP services provided incident to a physician service should be billed, with Modifier SA, by the physician. Services not incident to a physician service should be billed by the APP.
- Facility setting (Inpatient Hospital/Urgent Care): In a facility setting, a service is sometimes provided by an APP in conjunction with a physician. In this situation, the provider who performs the substantive portion of the service should be the provider who bills for the service. Separate claims should not be submitted by each provider for the same service. When the APP is the sole provider of the service, reimbursement is made to the APP as the billing provider.
Contracting and credentialing scenarios
This table presents the requirements, across various settings, for the contracting and credentialing of APPs.
Primary Care Practice: Blended Physician & Advanced Practice
Provider (APP)
| Y
| Y
|
Primary Care Practice: CRNP-only Practice*
| Y
| Y
|
Behavioral Health Practice: Blended Physician & APP
| Y
| Y
|
Behavioral Health Practice: CRNP-only Practice*
| Y
| Y
|
Medical Specialist Practice: Blended Physician & APP
| Y
| Y
|
Medical Specialist Practice: CRNP-only Practice*
| We only contract with CRNP-only medical specialist practices when the
CRNP is board-certified in the specialty in which they practice.
| We only credential CRNP-only medical specialist practices when the CRNP
is board-certified in the specialty in which they practice.
|
Hospital Inpatient
| Y
| Y
|
Urgent Care
| Y
| Y
|
*PAs are not contracted or credentialed for APP-only practice.
To complete the credentialing process, please visit the AmeriHealth Professional Provider Credentialing webpage. If you have already been credentialed, there is no need to resubmit a credentialing application.