NPP types of service and coverage

Medicare: Coverage is limited to the services an NPP is legally authorized to perform in accordance with state law. Traditional examples of the types of services that these practitioners may provide include services such as physical exams, minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. Services may be covered under Part B, if all the following are met:
• They are the type that are considered physician’s services if furnished by an MD or DO;
• They are performed by a person who meets the definition of an NPP or qualifies as a CNS;
• They are performed under the supervision of an MD/DO (for PA’s only) or are
performed in “collaboration” with an MD/DO (for NPs and CNS’s only);
• The practitioner is legally authorized to perform the services in the state in which they are performed; and,
• The practitioner is legally authorized to perform the services in the state in which they are performed; and,
• They are not otherwise non-covered.

Medicaid: NPP services must be delivered according to protocols developed jointly with the physician, and must be in accordance with the scope of practice and state law governing APNs and PAs.
APNs- Services performed by APNs are covered if the services meet the following criteria:
• Within the scope of practice for APNs, as defined by state law;
• Consistent with rules and regulations promulgated by the Board of Nurse
Examiners for your state or other appropriate state licensing authority;
• Covered by your state’s Medicaid Program when provided by a licensed
physician (MD or DO); and,
• Are reasonable and medically necessary as determined by your state
department of health or its designee. APNs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill for their services if that billing would result in duplicate payment for the same services. Benefit limitation information for services may be found in the specific sections of your state’s Medicaid Provider Procedures Manual.
PA- Services are billed under the physicians name and provider number.

Commercial Plans: May vary from carrier to carrier. Make sure to read contracts and/or call carriers. Coverage should be consistent with scope of practice.
Some states have rules that prohibit insurers from discriminating against NPPs for providing covered services they are licensed to perform. Please consult your state’s laws and regulations.

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