This FAQ was revised on November 6, 2020.
The following frequently asked questions (FAQ) were developed to answer
questions about Independence Blue Cross’s (Independence) 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 Independence 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 Independence 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.
This applies to both commercial and Medicare Advantage members.
- Mandating that CRNPs and PAs be appropriately credentialed.
Note: This document will be updated as additional information
becomes available.
2. What is the effective date of the
credentialing requirements and reimbursement position for CRNPs and PAs?
(Revised 11/6/20)
Credentialing requirements
Effective June 1, 2019, all CRNPs and PAs will be required
to be credentialed to provide services to
Independence members. For more information on credentialing requirements and
processes, please see question 6.
Reimbursement position
The following policies will be 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)
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 policies currently in effect.
3. Who will be affected by these
updates?
The updated policies only impact CRNPs and PAs who perform services under
the supervision of a physician in the professional setting.
4. Are there any exclusions to the updated
policies?
Yes. “Incident to” policies do not apply to the facility
setting. There are also certain specialties to which these policies do 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 Independence
members. Please allow up to 45 business days to process
applications.
For more information on our network credentialing process and credentialing
criteria, please visit our Professional Provider Credentialing webpage. CRNPs and
PAs should apply for credentialing by completing the Practitioner Participation Form.
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 ProViewTM.
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
Independence 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 UpdateSM, our online provider
newsletter;
- Independence 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:
- Independence Medical
Policy Portal;
- Partners in Health Update;
- Independence NaviNet Open Plan Central in a message containing a summary of
the changes to the policies 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;
- Independence 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;
- Independence 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;
- Independence NaviNet Open Plan Central in a message.
CRNP contracting and credentialing scenarios (Added 9/17/19)
CRNPs are only permitted to be contracted and credentialed with Independence
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 Independence.
|
CRNP-only specialist office
|
Not allowed
|
|
CRNP-only hospital or nursing home practice
|
Not allowed
|
|
For more information
Please refer to the Medical Policy Portal to view the most recent version of
these policies, as they 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@ibx.com. Please be sure to include your name,
contact number, and provider ID in your email.
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