Anthem’s direct contracting effort for Certified Nurse Specialists gets underway in 2021

The Commonwealth of Virginia House Bill 1057 – Certified Nurse Specialist (CNS), which became effective July 1, 2020, allows CNS providers to be reimbursed directly for Covered Services performed within their scope of license.  HB1057 removed the previous limitation that only allowed licensed CNS providers to be reimbursed for covered mental health services.

 

As a result of this legislation, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will now be contracting directly with Certified Nurse Specialists for these additional Covered Services so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  Direct contracting means Certified Nurse Specialists should now bill Anthem directly and the “incident to” guidelines will no longer apply.

 

This impacts all lines of business:

 

• Anthem’s PAR/PPO/EPO 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).

 

• Anthem HealthKeepers Plus (Medicaid/FAMIS and the Commonwealth Coordinated Care Plus plans).

 

• Medicare Advantage health plans.

 

How Anthem’s credentialing and contracting process will work

 

We are offering contracts now with the expectation that all CNS providers working in a professional practice setting will begin the credentialing and contracting efforts immediately.  This requirement does not apply to CNS providers who work strictly in a facility setting as these services are included in the facility reimbursement.

 

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

 

Contracts may be requested through Availity.com.  If you or your organization need guidance on the contracting process through Availity, please contact your Network Manager.

 

Other than the “provider type” description, the participation agreement will contain the same provisions and obligations as our standard provider agreements.  Fee schedule allowances are clearly displayed in the Plan Compensation Attachment section of the contracts.  CNS providers may choose between a Primary Care (PCP), Specialist, or Behavioral Health contract.  While CNS providers may elect a PCP contract so that appropriate member cost-shares are applied in a PCP practice, members will not be able to select a CNS as a PCP.  CNS providers should select the appropriate contract based on the type of services their office provides. 

 

Benefits of direct contracting for CNS providers

 

This direct contracting and credentialing approach with Certified Nurse Specialists allows us to include these providers in our provider directories, and our members – your patients – can easily search our provider finder tool for CNS providers who participate with members’ health plans.

 

In addition, direct contracting with Certified Nurse Specialists will allow easier handling of Medicare crossover claims.  Medicare crossover claims for services provided by Certified Nurse Specialists to our members with a secondary group coverage policy will process under the participating CNS provider’s record, all without any re-billing by the group under the physician’s NPI.

 

967-0221-PN-VA