As previously communicated in a Partners in Health UpdateSM article, in order to align with the Centers for Medicare & Medicaid Services (CMS) and industry standards for “incident to” billing practices, Independence will be updating its policies on reimbursing certified registered nurse practitioners (CRNP) and physician assistants (PA). The following policies were posted as Notifications on March 1, 2019, and will go into effect June 1, 2019:
- Commercial: #00.10.40c: Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
- Medicare Advantage: #MA00.045c: Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
Policy updates
Independence will update its policies 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 Independence at 100 percent of the standard vaccine and injectable fee schedule.
Exclusions
There are certain specialties to which these policies do not apply, including hospital-based specialties (e.g., hospitalist, emergency medicine) and urgent care practices.
Becoming a credentialed CRNP or PA
As previously communicated, effective June 1, 2019, all certified CRNPs and PAs will be required to be credentialed to provide independent, unsupervised services to Independence members.
To learn more on how to become a credentialed CRNP or PA, please read the article, Reminder: Updated credentialing requirements for CRNPs and PAs.
For more information
To view the Notifications for the expanded policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, and then select Commercial or Medicare Advantage under 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 Independence 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@ibx.com. Please be sure to your name, contact number, and provider ID in your email.
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