Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
Annual Review
Prepared By
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options services for Physician Assistants and Advanced Practice Registed Nurses.
Definitions
Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.
Participating Provider: Any provider, group of providers, or entity that is employed by or has signed a provider participation agreement with the Contractor or Subcontractor, is credentialed by Highmark Health Options, and receives Medicaid funding directly or indirectly to order, refer, or provide Health Care Services.
Non-Participating Provider: Any provider, group of providers, or entity that accepts Medicaid but does not agree to take assignment in all cases. They do not have a contract and are not credentialed with Highmark Health Options.
Advanced Practice Registered Nurses (APRN)1 are defined as the following:
· Certified Nurse Practitioner (CNP)
· Clinical Nurse Specialist (CNS)
· Certified Registered Nurse Anesthetist (CRNA)
· Certified Nurse-Midwife (CNM)
· Psychiatric-Mental Health Clinical Nurse Specialist (PMHCNS-BC)
· Psychiatric-Mental Health Nurse Practitioner (PMHNP-BC)
· Psychiatric-Mental Health Advanced Practice Nurse (PMH-APRN)
Policy Position
Procedures
HHO will allow participating PA(s) and APRN(s) who are billing as full practice authority in the professional setting to be paid in alignment with the applicable fee schedule. PA(s) and APRN(s) and their employers may continue to rely on other billing options such as split/shared billing in a facility and billing under the “incident-to” rule in an outpatient setting.
References
NCSBN. (n.d.). APRNs in the U.S. NCSBN.Org. https://www.ncsbn.org/aprn.htm
