Medical Policy:
Eligible Providers
Effective Date:
May 24, 2021
Issued Date:
May 24, 2021
Last Revision Date:
April 2021
Annual Review:
April 2021

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).

Policy Position

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
  • Physician assistants
  • 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.

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. 


Related Policies

Refer to Reimbursement Policy RP-010, Incident To Billing, for additional information.

The policy position applies to all commercial lines of business



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

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.