Certified registered nurse practitioners (CRNPs) provide health care to all age groups of patients based on their training. For example, CRNPs perform comprehensive and focused physical examinations, diagnose and treat common illnesses and injuries, provide immunizations and education, and manage high blood pressure, diabetes, and other chronic health problems. CRNPs can order and interpret diagnostic tests, such as X-rays, EKGs, and laboratory tests. They can also prescribe medications and therapies and can perform certain procedures (based on state/national practice guidelines).
Contracting and credentialing requirements
A CRNP must meet all of the requirements of
AmeriHealth New Jersey and
AmeriHealth Pennsylvania credentialing criteria and have a collaborative agreement with a participating physician who holds a current and unrestricted license. The training and scope of practice of the collaborating physician must be consistent with the practice of the CRNP.
The agreement must comply with current applicable state and federal regulations.
Contracting and credentialing scenarios
CRNPs are only permitted to be contracted and credentialed with AmeriHealth under the following scenarios:
|
Scenario |
Allowed/Not allowed |
Notes |
|---|
Physician PCP office | Allowed | CRNPs bill under their own National Provider Identifier (NPI) number unless service meets “incident to” guidelines (physician does not need to be in the office for CRNP to see members). |
CRNP-only PCP office (no physician present) | Allowed | CRNPs must have a collaborative physician agreement. |
Physician specialist office | Allowed | CRNPs bill under their own NPI number unless it meets “incident to” guidelines. A physician must be present in the office for at least 75 percent of the hours in which the office is scheduling patients for a CRNP to be contracted and credentialed with AmeriHealth. |
CRNP-only specialist office | Not allowed | |
CRNP-only hospital or nursing home practice | Not allowed | |
Learn more
More information about our credentialing process can be found on our credentialing webpages for
AmeriHealth New Jersey or AmeriHealth Pennsylvania.
FAQ
The information in this article has also been added to 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® web portal (NaviNet Open) 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.
Policies
As a reminder, as of June 1, 2019, AmeriHealth updated Claim Payment Policy: #00.10.40c: Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs) regarding reimbursing CRNPs.
To view this policy, visit our
Medical Policy Portal.
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