Wiki NP billing when MD is not present

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Hi, I am so confused and need help. I understand the incident-to guidelines for Medicare. My question is more regarding for example Cigna, Humana, HealthNet Ambetter, types of plans that do not credential or contract NP's. What is the correct way to bill for a patient (new or established) when a NP sees that Pt with that kind of insurance when there is no MD in office and it is NOT a incident to type of situation?
Any documentation would be helpful as well, as I have read the Provider guidelines and sometimes they differ than Medicare, so who do you abide by?
Thanks in advance,
Shannon
 
Sorry but there is no one answer to this. You have to follow the guidelines of the carrier. I will note that most commercial carriers do credential and contract NPs and PAs. I work for a large healthcare organization and our PAs get credentialed just like our MDs do with the exception of only a few carriers. In general carriers want to credential the NPPs, so they have the opportunity to pay less for the services they render.
Abide by the Medicare guidelines for Medicare patients. Abide by the specific carrier guidance for your other patients.
Here's an old, but good article from AAFP regarding this https://www.aafp.org/fpm/2006/0500/p45.html
 
Agree with what Christine said above. It seems odd that a PA or NP would not be credentialed w/ a plan like that. You would have to follow the payer rules. In some cases I have seen where practices don't schedule new patients with mid-levels and only schedule established patients but that's not always practical and may not even make sense for your question. You also have to consider state scope of practice for the NPP/APP. In general if a provider is not credentialed with the patient's insurance they should not see the patient and direct-bill. Some practices use the "when in doubt follow Medicare" idea for billing but that's not really a good idea in all cases either depending on the payer.
This is a 2017 AMA grid for reference: https://www.ama-assn.org/sites/ama-...group/arc/ama-chart-np-practice-authority.pdf
 
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