Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-27 |
Topic: | Eligible Providers and Supervision Guidelines |
Effective Date: | January 1, 2006 |
Issued Date: | February 13, 2006 |
Date Last Reviewed: |
Indications and Limitations of Coverage
For reimbursement by Highmark Blue Shield, covered services must be personally performed by an eligible professional provider or under that provider's direct personal supervision (in accordance with the licensure and employment criteria outlined below). Eligible professional providers are those providers defined by Blue Shield's Regulatory Act (i.e., Enabling legislation), duly licensed and acting within their scope of license. They include:
Blue Shield will also reimburse covered services performed by licensed health care practitioners, who are employed and personally supervised by eligible professional providers. For purposes of this guideline, "health care practitioner" is defined as a person who is licensed to perform health-related services, but is not eligible for direct reimbursement from Blue Shield. Examples of health care practitioners include Registered Nurses (R.N.s), Licensed Practical Nurses (L.P.N.s), Physician Assistants, and licensed Clinical Social Workers. See Medical Policy Bulletin Z-33 for employment criteria. See Medical Policy Bulletin Z-10 for information on Physician Assistants.
For reimbursement purposes, Blue Shield requires that services reported for its members are either personally performed by the eligible professional provider or under that provider's direct personal supervision, as outlined in these guidelines.
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Traditional (UCR/Fee Schedule) Guidelines
FEP also considers Nutritionists, Licensed Clinical Social Workers, and beginning 1/1/06, Acupuncturists as eligible providers. |
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.
Managed Care (HMO/POS) Guidelines
The Keystone Health Plan West (KHPW) network is not governed by Highmark's Enabling legislation. |
PRN References |