Anthem’s direct contracting effort for NPs and PAs gets under way in 2019

In 2019, Anthem Blue Cross and Blue Shield in Virginia and our affiliate HealthKeepers, Inc. will launch an effort that will allow us to begin direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs), so they may begin billing their services under their own 10-digit National Provider Identifier (NPI).  This effort will impact all 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).

 

• Anthem HealthKeepers Plus [Medicaid/FAMIS and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) plans].

 

• Medicare Advantage health plans.

 

As you may know, Virginia legislation went into effect on July 1, 2018, allowing nurse practitioners who meet certain work history requirements to begin practicing independently.  Licensed NPs and PAs currently 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 and the “incident to” guidelines will no longer apply.

 

How Anthem’s contracting process will work

 

We expect to begin the contracting effort sometime in the second quarter of 2019 by reaching out to network-participating providers we know currently employ NPs and PAs. Please note that the new participation agreement WILL NOT apply to certified nurse midwives, clinical nurse specialists, or psychiatric/mental health nurse practitioners, as they are contracted under a separate agreement.

 

Other than the provider type description, the participation agreement will contain 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 percent of the Medicare rate for these provider types.

 

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 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.]

 

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 on our provider directories as independent providers, and our members – your patients – can easily search 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 re-billing by the group under the physician’s NPI.

 

Looking ahead

 

Going forward, we’ll keep you informed of details and the date contracted NPs and PAs can begin billing directly for their services.  Watch for upcoming editions of our provider newsletter for further details.