Highmark Medical Policy Bulletin |
Section: | Miscellaneous |
Number: | Z-27 |
Topic: | Eligible Providers and Supervision Guidelines |
Effective Date: | January 14, 2005 |
Issued Date: | October 17, 2005 |
Date Last Reviewed: |
Indications and Limitations of Coverage
Covered services provided for members must be personally performed by an eligible professional provider, or under the provider's direct personal supervision. The following providers are eligible when, duly licensed and acting within the authority of their licenses:
Covered services performed under the personal supervision of an eligible provider by a licensed health care practitioner (e.g., physician's assistant, licensed clinical social worker, and registered physical therapy assistant) in his or her employment may be eligible. (See Medical Policy Bulletin Z-33 for information on employment relationship criteria. See Medical Policy Bulletin Z-10 for information on physician's assistants. See Medical Policy Bulletin Y-1 for information on physical medicine.) "Personal supervision" means that the provider must be in the immediate vicinity so that he or she can personally assist in the procedure, or to assume primary care of the patient, if necessary. Such services are eligible only if the criteria of appropriate licensure, employment, and supervision are met. (See Medical Policy Bulletin A-3 for additional information on supervision of anesthesia services.) Availability of the provider by telephone does not constitute direct personal supervision. 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
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
PRN References |
[Version 008 of Z-27] |
[Version 007 of Z-27] |
[Version 006 of Z-27] |
[Version 005 of Z-27] |
[Version 004 of Z-27] |
[Version 003 of Z-27] |
[Version 002 of Z-27] |
[Version 001 of Z-27] |