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:

• Audiologists
• Certified registered nurses
  - Certified registered nurse anesthetists
  - Certified registered nurse practitioners
  - Certified enterostomal therapy nurses
  - Certified community health nurses
  - Certified psychiatric mental health nurses
  - Certified clinical nurse specialists
• Clinical laboratories
• Dentists
• Doctors of chiropractic
• Doctors of medicine
• Doctors of osteopathy
• Nurse midwives
• Optometrists
• Physical therapists
• Podiatrists
• Psychologists
• Speech pathologists
• Teachers of the hearing impaired

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 (PAs), and licensed Clinical Social Workers (LCSWs).

Eligible professional providers (as listed above) are not subject to these employment and /or direct personal supervision requirements.  Rather, they are governed by the state licensure regulations applicable to their profession.

"Personal supervision" means that the professional provider must be present in the immediate vicinity, in the event his or her personal assistance is required for the procedure or to assume care of the patient. For purposes of this guideline, "immediate vicinity" is defined as within the same office or suite of offices, so that the professional provider can respond promptly to a request for assistance. Availability of the supervising professional provider by telephone does not constitute direct personal supervision.

When providing care to his or her patient, the professional provider has medical and legal responsibility for the services rendered. 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.

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.

There may be exceptions to this policy depending on the individual member's contract, and provider network rules.

See Medical Policy Bulletin Z-33 for employment criteria.

See Medical Policy Bulletin Z-10 for information on Physician Assistants.

FEP considers the following to be covered professionals when they perform services within the scope of the license or certification:

Physicians:

• Doctors of Medicine (M.D.);
• Doctors of Osteopathy (D.O.);
• Doctors of Dental Surgery (D.D.S.);
• Doctors of Medical Dentistry (D.M.D.); 
• Doctors of Podiatric Medicine (D.P.M.); 
• Doctors of Optometry (O.D.); and
• Doctors of Chiropractic (D.C.)

Other Covered, Licensed Health Care Professionals:

• Acupuncturist (Acupuncture must be performed and billed by a physician or licensed acupuncturist)
• Audiologist
• Clinical Psychologist
• Clinical Social Worker
• Diabetic Educator
• Dietician
• Independent Laboratory
• Nurse Midwife
• Nurse Practitioner/Clinical Specialist
• Nursing School Administered Clinic
• Nutritionist
• Physical, Speech, and Occupational Therapist
• Physician Assistant

The Keystone Health Plan West (KHPW) network is not governed by Highmark's Enabling legislation.

PRN References

06/1994, New providers now eligible to participate with Blue Shield
10/1994, Supervision guidelines
08/1995, Massage therapists' services
08/1999, Chiropractic assistants' services not covered
10/1999, Certified Registered Nurses
10/1999, Physician Assistants
04/2000, Eligibility requirements for supportive personnel
02/2005, Massage therapists services not eligible
06/2006, Supervision guidelines outlined