This FAQ was revised on November 6, 2020.

The following frequently asked questions (FAQ) were developed to answer questions about the AmeriHealth updated credentialing requirements and reimbursement position for certified registered nurse practitioners (CRNP) and physician assistants (PA).

Note: This document will be updated as additional information becomes available.

1. Why is AmeriHealth updating its credentialing requirements and reimbursement position for CRNPs and PAs?

The number of practicing physicians is not expected to meet the demands of our aging population and it is likely that our reliance on non-physician practitioners, such as CRNPs and PAs, will continue to grow.

As our health care systems’ reliance on CRNPs and PAs increases, it is necessary for health insurers like AmeriHealth to review – using industry benchmarks and best practice standards – how non-physician practitioners are credentialed and how they bill for their services.

After evaluating how CRNPs and PAs in our network are currently being credentialed and how they bill for their services, we have decided to align with Centers for Medicare & Medicaid Services (CMS) and industry standards by:

• Following the CMS definition of “incident to” in the professional setting.
• Reimbursing CRNPs and PAs who perform “non-incident to” services at 85 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement. There will not be a change to those performing “incident to” services with reimbursement at 100 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement.
• Distinguishing between servicing providers (e.g., medical doctor vs. CRNP/PA) for services billed under a physician’s NPI with Modifier SA.
• Mandating that CRNPs and PAs be appropriately credentialed.

2. What is the effective date of the credentialing requirements and reimbursement position for CRNPs and PAs?

(Revised 11/6/20)

Effective June 1, 2019, all CRNPs and PAs will be required to be credentialed to provide ​​​services to AmeriHealth members. For more information on credentialing requirements and processes, please see question 6.

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.

Note: Between the publication of this FAQ and June 1, 2019, practices should continue to bill CRNP and PA services as they currently do under the policy currently in effect.

3. Who will be affected by these updates?

The updated policy only impacts CRNPs and PAs who perform services under the supervision of a physician in the professional setting.

4. Are there any exclusions to the updated policy?

Yes. The “incident to” policy does not apply to the facility setting. There are also certain specialties to which this policy does not apply, including hospital-based specialties (e.g., hospitalist, emergency medicine) and urgent care practices.

5. What are the CMS reimbursement guidelines for CRNPs and PAs?

CMS currently reimburses non-physician practitioners, such as CRNPs and PAs, as follows:

• “Incident to” services are defined as those services that are furnished “incident to” physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home (if homebound). These services are paid at 100 percent of the physician fee schedule, subject to the specific terms and conditions of the participation agreement. The conditions for billing “incident to” are:
• The individual must be an established patient, and the service must be treatment for an existing problem.
• The treatment course must have been initiated by a physician at a previous encounter.
• The service must be an integral part of the patient's course of treatment.
• The physician must remain involved in the treatment plan.
• The service must be of a type commonly furnished in a physician’s office or clinic (not in an institutional setting).
• The service must be provided under direct supervision, meaning the supervising physician (or a supervising partner) must be in the same office suite to render assistance if necessary.
• The service must be an expense to the physician's practice.
• CRNPs and PAs who are performing “non-incident to” services (services performed and billed using their own NPI number, rather than a physician’s) are reimbursed at 85 percent of the standard physician fee schedule, subject to the specific terms and conditions of the participation agreement.

6. How should CRNPs and PAs get credentialed?

To meet the June 1, 2019 deadline, credentialing applications should be submitted prior to April 1, 2019. Credentialing applications received after April 1, 2019, may not be processed prior to June 1, 2019. CRNPs and PAs not credentialed by June 1, 2019, will not be able to render services to AmeriHealth members. Please allow up to 45 business days to process applications.

For information on our network credentialing process and credentialing criteria, please visit the following credentialing webpages for AmeriHealth New Jersey or AmeriHealth Pennsylvania.

CRNPs and PAs should apply for credentialing by completing the online Practitioner Participation Form for AmeriHealth New Jersey or AmeriHealth Pennsylvania.

Any professional provider interested in participating in our network must complete a Practitioner Participation Form. You can simplify this process by using the Council for Affordable Quality Healthcare’s (CAQH) online credentialing application: CAQH ProView^TM.

Note: If you have already been credentialed, there is no need to resubmit a credentialing application.

7. What happens if a CRNP or PA is not credentialed by June 1, 2019?

If a CRNP or PA is not credentialed, they cannot provide services to AmeriHealth members until they have been credentialed.

8. How have providers been notified of these updates to the credentialing requirements and reimbursement position? (Revised 9/17/19)

• On December 12, 2018, and January 24, 2019, the updated credentialing requirements were announced to providers via:
  • Partners in Health Update^SM, our online provider newsletter, at amerihealth.com/pnc;
  • AmeriHealth NaviNet^® web portal (NaviNet Open) Plan Central in a message containing a summary of the updates.
• On March 1, 2019, the updated reimbursement positions were announced to providers via:
  • AmeriHealth Medical Policy Portal;
  • Partners in Health Update;
  • AmeriHealth NaviNet Open Plan Central in a message containing a summary of the changes to the policy and a link to the Medical Policy Portal.
• On April 3, 2019, providers were reminded of the updated reimbursement position and credentialing requirements via:
  • Partners in Health Update;
  • AmeriHealth NaviNet Open Plan Central in a message.
• On May 17, 2019, providers were reminded of the updated reimbursement position and credentialing requirements via:
  • Partners in Health Update;
  • AmeriHealth NaviNet Open Plan Central in a message.
• On September 17, 2019, providers were notified of important contracting and credentialing information for CRNPs via:
  • Partners in Health Update;
  • AmeriHealth NaviNetOpen Plan Central in a message.

CRNP contracting and credentialing scenarios (Added 9/17/19)

CRNPs are only permitted to be contracted and credentialed with AmeriHealth under the following scenarios:

For more information

Please refer to the Medical Policy Portal to view the most recent version of this policy, as it will supersede the information in this FAQ.

If you cannot find the information you are looking for here and have further questions, please email us at incidentto@amerihealth.com. Please be sure to include your name, contact number, and provider ID in your email.

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