Highmark Medical Policy Bulletin

Section: Miscellaneous
Number: Z-33
Topic: Employment Relationship Criteria
Effective Date: August 28, 2000
Issued Date: August 28, 2000
Date Last Reviewed:

General Policy Guidelines

An employment relationship is established if all of the following criteria are sufficiently documented:

  1. The employer has the power to hire and fire;
  2. The employer has the power to direct the work done by the employee and has ultimate responsibility for the manner of his/her performance;
  3. The employer has the duty to pay wages, fringe benefits, and establish the level of compensation;
  4. The employer is personally responsible for withholding federal income tax and social security contributions and is personally responsible for making contributions for the employee under the Pennsylvania Unemployment Compensation Act and is personally responsible for insuring the employee's liability under the Pennsylvania Workmen's Compensation Act; and
  5. There is no compensation received by any facility for the services of the employee during the period of employment by the employer.
See Medical Policy Bulletin Z-27 for information on services performed by an employee under the supervision of an eligible provider.

Procedure Codes


Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.