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:
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.
Refer to Reimbursement Policy RP-010, Incident To Billing, for additional information.
2020 DISCLAIMER
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:
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.
