An update about Anthem’s direct contracting effort for nurse practitioners and physician assistants

Category:  Medicare

 

 

As previously communicated in our March 2019 edition of Provider News, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. have launched an effort to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs). This means that NPs and PAs may begin billing their services under their own 10-digit National Provider Identifier (NPI). This effort will impact all of our lines of business:

 

• Anthem’s PAR/PPO health plans including the Blue Cross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or FEP)

 

• Anthem HealthKeepers commercial plans including health plans purchased on or off the Health Insurance Marketplace (also known as the exchange)

 

• Medicaid programs offered under the Anthem HealthKeepers Plus plan:

 

• FAMIS (CHIP) and Medallion (Medicaid)

 

• The Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) program for managed long-term services and supports

 

• Medicare Advantage health plans

 

Virginia legislation was passed in March 2019 that now requires payers to offer provider contracting opportunities to NPs who meet Anthem’s terms and conditions. This change is effective October 1, 2019. Currently, licensed NPs and PAs can only bill for covered services under the supervision of the employing/supervising participating physician (using that physician’s name and NPI number). Direct contracting means NPs and PAs will be allowed to bill Anthem directly for their services, and the “incident to” guidelines will no longer apply.

 

Benefits of direct contracting for NPs and PAs

 

This direct contracting and credentialing approach with NPs and PAs will allow us to include these providers in our provider directories as independent providers, and our members — your patients — can easily search via our Provider Finder tool for NPs and PAs who participate with members’ health plans.

 

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

How Anthem’s contracting process will work

 

Credentialing and contracting of NPs and PAs is now under way. Our network managers have begun reaching out to network-participating providers who we know currently employ NPs and PAs. Please note that the new participation agreement will not apply to certified nurse midwives or clinical nurse specialists, as they are contracted under a separate agreement.

 

Other than the provider type description, the participation agreement contains all of the same provisions and obligations as our standard physician agreements. The allowance schedule will be the same as the current standard physician allowance for our commercial and Medicaid agreements. For Medicare Advantage, we will reimburse NP and PA services at 100% of our Medicare Advantage rate for these provider types.

 

Contracts and network participation for NPs and PAs will not be effective any sooner than

September 1, 2019. After September 1, the individual provider’s effective date will be the later of the contract signature date or when credentialing is complete.

 

Credentialing process

 

NPs and PAs will be required to be credentialed through Anthem in Virginia. Therefore, NPs and PAs must complete the online application process through CAQH. To contact CAQH, dial 1-888-599-1771 (Monday through Thursday 7 a.m. to 9 p.m. ET; Friday 7 a.m. to 7 p.m. ET) or visit the CAQH website at http://www.caqh.org/ucd_physician_register.php