For reimbursement by the Plan, covered services must be performed by an eligible professional provider or performed under that provider's supervision (in accordance with the licensure, certification and/or employment criteria).

Eligible Professional Providers

Eligible professional providers are those providers duly licensed or certified by the state and acting within their state defined scope of license. They include:

• Audiologists
• Behavior health rehabilitation agency providers (solely for the diagnosis or treatment of autism spectrum disorders)
• Behavior specialist
• Certified registered nurses as follows:
  • Certified registered nurse anesthetists
  • Certified registered nurse practitioners (CRNPs can function as PCPs in pediatrics, internal medicine or family practice; or they can function as specialists in neonatology, diabetes management, women’s health, oncology, gerontology, psychiatry/mental health)
  • Certified registered nurse midwives
  • Certified enterostomal therapy nurses
  • Certified community health nurses
  • Certified psychiatric mental health nurses
• Clinical laboratories
• Dentists
• Doctors of chiropractic
• Doctors of medicine
• Doctors of osteopathy
• Licensed clinical social workers
• Licensed dietitian-nutritionists
• Marriage and family therapists
• Occupational therapists
• Optometrists
• Physical therapists
• Podiatrists
• Professional counselors
• Psychologists
• Speech pathologists 
• Teachers of the hearing impaired

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

Supervision Guidelines

The Plan will also reimburse covered services performed by state licensed or state certified health care practitioners, who are employed and supervised by eligible professional providers. For purposes of this guideline, "health care practitioner" is defined as a person who is state licensed or state certified to perform health-related services, but is not eligible for direct reimbursement from the Plan. Examples of health care practitioners include registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and physician assistants (PAs).

“Supervision" means that the eligible professional provider must be immediately available physically or by electronic means (e.g. telephone, radio, telecommunications), in the event his or her assistance or oversight is required in the care of the patient. All supervision must be in accordance with the state licensure or certification requirements of the performing licensed or certified health care practitioner.

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

For reimbursement purposes, the Plan requires that services reported for its members are either performed by the eligible professional provider or performed under such provider's supervision, as outlined in these guidelines.

Except as otherwise provided below, the eligible professional provider, or professional provider group must submit claims for services performed by the employed licensed or certified health care practitioner. Payment will be made to the eligible participating, preferred, or network professional provider, or professional provider group which employs the licensed or certified health care practitioner.

A behavior health rehabilitation agency provider must submit claims for services that may be eligible for coverage by the Plan performed by employees or contractors. Such provider will receive payment for any of said eligible services and has medical and legal responsibility for the services rendered.

Certain diagnostic tests have been identified that have extended technical components wherein the individual goes about normal daily activities while being monitored. These tests include Holter monitoring, cardiac event monitoring, and sleep studies. 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 state licensure or state 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

Employment Relationship:

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

• The employer has the power to hire and fire;
• The employer has the power to direct the work done by the employee and has ultimate responsibility for the manner of his/her performance;
• The employer has the duty to pay wages, fringe benefits, and establish the level of compensation; 
• There is no compensation received by any facility for the services of the employee during the period of employment by the employer.