Reminder: Mid-level practitioners are required to file using their NPI

Anthem Blue Cross and Blue Shield (Anthem) provides benefits for covered services rendered by Physician Assistants (“PA”) and Nurse Practitioners (“NP”) when operating within the scope of their license. Our "Incident to" Services Reimbursement Policy has been in place since 2017 and states that these mid-level practitioners are required to file for benefits using their specific NPI number -- not that of the medical doctor.

 

To ensure compliance with our policy requirements, claims filed by a PA or NP should be submitted using their individual NPI.

 

We will monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Reimbursement for services provided by PAs or NPs are subject to the Provider Contract terms and conditions, and the terms and conditions of Anthem’s policies and procedures. This includes its reimbursement policies, such as our "Incident to" Services Reimbursement Policy which provides in part as follows:

 

Anthem does not follow CMS “Incident to” reimbursement rules for any physician or non-physician provider (NPP) … therefore:

• If a provider has an NPI and is recognized by Anthem as eligible to submit claims directly to Anthem, then the provider is required to report his/her services under his/her own NPI.
• Separately reportable “Incident to” services are only eligible for reimbursement under the supervising provider’s NPI if the specific type of NPP or qualified auxiliary office personnel who rendered the services is ineligible to submit claims directly to Anthem; this rule will apply even when a provider is in the process of applying for his/her own NPI number.

 

Reimbursement Policies are available online at anthem.com. Select Providers │ under Provider Resources heading, select Policies and Guidelines (Note: select Colorado, if you haven’t done so already) │ Under Reimbursement Policies heading, select Access Policies, then the "Incident to" Services policy. 

 

Action Required:

If your PAs and/or NPs have an NPI, but are not linked to your TIN, please submit each applicable PA and/or NP through our New Provider Enrollment Application tool.  The New Provider Enrollment Application tool is available online at anthem.com. Select Providers │ under Join Our Networks heading, select Getting Started with Anthem (Note: select Colorado, if you haven’t done so already). 

 

IMPORTANT TIP:  If you have 10 or more PAs and/or NPs to submit at one time, please submit using our Roster Load for PA and NP Adds (Non-PCP) - 10 or more spreadsheet, rather than using the New Provider Enrollment Application.  Currently the New Provider Enrollment Application requires CAQH ID field to be entered.  PAs and NPs do not require credentialing, but they can obtain a CAQH ID to utilize the online application.  If you have more then 10+ PAs and/or NPs, you may utilize the Roster Spreadsheet to avoid having to apply for a CAQH ID for each of these providers.

 

Note:  If an NP intends to be a Primary Care Provider (PCP), they must be credentialed and follow the New Provider Enrollment Application process.

 

Access the Roster Load document online.  Go to anthem.com > Providers > Under the Provider Resources heading, select Forms and Guides > Roster Load for PA and NP Adds (Non-PCP) - 10 or more.  As indicated on the spreadsheet, once completed, email to COProviderRelations@anthem.com.

 

Training for utilizing the New Provider Enrollment Application:

If you need assistance with the New Provider Enrollment Application process, please access our recorded webinar regarding this topic.  Use the following access code to view this webinar WwA102019.  (Access code is case sensitive).

 

Anthem recognizes the quality of care delivered to our members can be improved by the proper use of ARNPs, CNSs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how their services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please contact your Contract Manager.