Catergory:  Medicare

Earlier in the year, we notified you of our plans to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs) in Virginia. Once contracted and credentialed, NPs and PAs can begin billing services under their own 10-digit NPI. In addition to Medicare Advantage plans under Anthem Blue Cross and Blue Shield (Anthem), this effort will impact other health plans in Virginia.


As you may know, Virginia legislation went into effect on July 1, 2018, allowing NPs who meet certain work history requirements to begin practicing independently. Before this legislation took effect, licensed NPs and PAs could only bill for covered services under the supervision of the participating physician using that physician’s name and NPI. With this change, NPs and PAs must bill Anthem directly and the “incident to” guidelines will no longer apply.


CMS defines “incident to” services as services billed by physicians and nonphysician practitioners 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. Please note that the new participation agreement will not apply to certified nurse midwives as they are contracted under a separate participation agreement.

How the contracting process will work


We began the direct contracting effort for NPs and PAs in the second quarter of 2019. We will be reaching out to participating providers who we know currently employ NPs and PAs.

Other than the provider type description, the participation agreement will contain the same provisions and obligations as our standard physician agreements. For Medicare Advantage, we will reimburse NP and PA services at 100% of the Medicare rate for these provider types.

Credentialing process


NPs and PAs are required to be credentialed through Anthem in Virginia. Therefore, NPs and PAs must complete the online application process through the Council for Affordable Quality Healthcare, Inc. (CAQH). To contact CAQH, call 1-888-599-1771 Monday through Thursday, 7 a.m. to 9 p.m. Eastern time or Friday, 7 a.m. to 7 p.m. Eastern time. You may also visit the CAQH website at:


Benefits of direct contracting for NPs and PAs


This direct contracting and credentialing approach will allow us to include NPs and PAs in our provider directories as independent providers. Our members can easily search our provider finder tool for participating NPs and PAs.


In addition, direct contracting with NPs and PAs will allow for simplified handling of Medicare crossover claims. Medicare crossover claims for services provided by NPs and PAs to members holding a secondary group coverage policy will process under the participating NP or PA record — without rebilling by the group under the supervising physician’s NPI.


Looking ahead


Going forward, we will keep you informed of details and the date contracted NPs and PAs can begin billing directly for their services. Please refer to our provider newsletter for further details.



Featured In:
December 2019 Anthem Provider News - Virginia