Direct contracting for nurse practitioners and physician assistants in 2019

Category:  Medicaid

In 2019, we began direct contracting and credentialing of nurse practitioners (NPs) and physician assistants (PAs) in Virginia. Once contracted and credentialed, Anthem HealthKeepers Plus NPs and PAs can begin billing services under their own 10-digit NPI.

Virginia legislation passed in March 2019 requires payers to offer provider contracting opportunities to nurse practitioners who meet HealthKeepers, Inc.’s terms and conditions effective October 1, 2019. Currently, licensed NPs and PAs can 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 HealthKeepers, Inc. 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. 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

 

Credentialing and contracting of NPs and PAs is now underway. 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 will contain the same provisions and obligations as our standard physician agreements.

Credentialing process

 

NPs and PAs are required to be credentialed through HealthKeepers, Inc. Therefore, NPs and PAs must complete the online application process through the Council for Affordable Quality Healthcare, Inc. (CAQH).

 

To join CAQH ProView®:

 

1. Go to https://proview.caqh.org/pr.
2. Select register now on the bottom right and follow the instructions.

 

If you already participate with CAQH and have completed your online application, ensure you authorized HealthKeepers, Inc. access to your credentialing information.

Note: If you have selected Global Authorization, HealthKeepers, Inc. will already have access to your data. To authorize HealthKeepers, Inc.:

 

1. Go to https://proview.caqh.org/pr and enter your username and password.
2. Select the cog wheel in the upper right and then select Authorize.
3. Scroll down, locate Anthem and check the box beside Anthem.
4. Select Save to submit your changes.

For questions about CAQH ProView, call the CAQH help desk at 1-888-599-1771 or email providerhelp@proview.CAQH.org.

 

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.

 

If you have any questions about this communication, call Provider Services at 1‑800‑901‑0020 or Anthem CCC Plus Provider Services at 1‑855‑323‑4687.