Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-27 |
Topic: | Eligible Providers and Supervision Guidelines |
Effective Date: | September 18, 2006 |
Issued Date: | September 18, 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. NOTE: The technical component of diagnostic tests may be performed by technicians who have appropriate training and proficiency, as evidenced by licensure or certification from the appropriate state health or education department. In the absence of a state-level licensure or certification, the technician must be certified by the appropriate national credentialing body. In these cases, payment can be made to the provider who supervises and employs the licensed or certified technician. See Medical Policy Bulletin Z-33 for employment criteria. See Medical Policy Bulletin Z-10 for information on Physician Assistants. When providing care to his or her patient, the professional provider has medical and legal responsibility for the services rendered, whether performed personally or by a licensed employee. This includes the ability to take over the procedure or to care for the patient in the event it's necessary. For example, patients may experience an acute medical problem (e.g., syncopal episode, cardiac arrest) even during non-invasive diagnostic procedures. It's also possible for equipment failure to result in circumstances which require patient management by a physician. 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. Certain diagnostic tests have been identified that have extended technical components wherein the patient goes about normal daily activities while being monitored. These tests include holter monitoring (93224, 93230, 93235), cardiac event monitoring (93268), and sleep studies (95807-95811). These procedures are performed under the physician's overall management and control, but the physician is not present for the duration of the test.
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Traditional (UCR/Fee Schedule) Guidelines
FEP considers the following to be covered professionals when they perform services within the scope of the license or certification: Physicians:
Other Covered, Licensed Health Care Professionals:
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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 |