Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 02|01|2002 POLICY LAST UPDATED: 02 |15|2023

OVERVIEW This policy documents/defines advanced practice providers (APPs) and the reimbursement guidelines/methodology/levels for covered health services when rendered by a Blue Cross & Blue Shield of Rhode Island (BCBSRI) credentialed APPs. State laws, which may vary, delineate the scope of practice for Advance Practice Providers (APPs).
The following are considered Advance Practice Providers: • Certified Clinical Nurse Specialist (CNS) • Psychiatric and mental health clinical nurse specialists (PMH-CNSs) • Certified Nurse Practitioner (NP) • Physician Assistant (PA) • Certified Registered Nurse First Assistant (CRNFA) • Certified Nurse Midwife (CNM) • Certified Registered Nurse Anesthetist (CRNA)

PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Services performed by APP’s such as evaluation and management services are reimbursed at a contracted proportion of the physician fee schedule as more specifically outlined in BCBSRI’s Coding and Payment Guideline policy and its fee schedules.

However, the following services when billed by an APP will be reimbursed at 100%of the full physician fee schedule allowance when considered a covered health service and reimbursed separately: a. Laboratory services
b. Injected or infused drugs c. Supplies d. After-hours services. Diagnostic tests s

Incident To
"Incident-to" services: BCBSRI does not follow CMS guidelines regarding incident to services and does not reimburse physicians for incident to services performed by Advanced Practice Providers. APPs must be individually credentialed by BCBSRI and filed under their own National Provider Identifier number.

Assistant-at-Surgery: Payment for assistant-at-surgery shall follow the same rules for eligible procedures as for physicians. Assistant-at-surgery services are eligible for payment when rendered by a CRNFA, PA, NP or CNS. Assistant at surgery claims for PAs, NPs and CNSs must be submitted with the AS modifier.

Anesthesia services:
Payment Policy | Advanced Practice Providers (APPs)

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BCBSRI requires the use of anesthesia modifiers to report the services of the CRNA and physician, when applicable.

Physician Assistants (PA): BCBSRI contracts with PAs who meet credentialing requirements to provide covered health services.
PAs providing or arranging services for patients may make order and/or referrals (only if they are credentialed as a PCP by BCBSRI) to specialists, diagnostic tests (laboratory, machine tests and imaging studies, etc.), home care, durable medical equipment (DME), supplies and as allowed by their prescriptive privileges, e.g. medications including injected or infused drugs and biologics.

MEDICAL CRITERIA None BACKGROUND The term “Mid-Level Provider” is used by the US Department of Justice’s Drug Enforcement Administration (DEA) to identify a group of health-care individuals for the purpose of monitoring-controlled substances, referred to as “Advanced Practice Providers” throughout this policy. According to the website of the DEA, Office of Diversion Control, “Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term advanced level provider means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of advanced practice providers include, but are not limited to, healthcare providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice.” Medicare uses the term “non-physician practitioner” to describe advanced practice nurses (APNs) and PAs.

Rhode Island General Laws§ 5-34-3 State of Rhode Island and Providence Plantations, Department of Health Rules and Regulations for the licensing of professionals defines the scope of practice for each level.
(1) “Advanced practice registered nurse” (APRN) is the title given to an individual licensed to practice advanced practice registered nursing within one of the following roles: certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA) as defined in chapter 34.2 of this title, or certified clinical nurse specialist (CNS), and who functions in a population focus. An APRN may serve as a primary or acute- care provider of record. (2) “Advanced practice registered nursing” means an independent and expanded scope of nursing in a role and population focus approved by the board of nurse registration and nursing education that includes the registered nurse scope of practice and may include, but is not limited to, performing acts of advanced assessment, diagnosing, prescribing, and ordering. Each APRN is accountable to patients, the nursing profession, and the board of nursing for complying with the requirements of this chapter and the quality of advanced nursing care rendered; recognizing limits of knowledge and experience; planning for the management of situations beyond the APRN's expertise; and for consulting with or referring patients to other healthcare providers as appropriate. (3) “Certified clinical nurse specialist” is an advanced practice registered nurse who independently provides care to clients; facilitates attainment of health goals; and provides innovation in nursing practice, based on clinical expertise, evidence-based decision-making, and leadership skills. The clinical nurse specialist practices with individual clients and populations; nurses, and other multidisciplinary team members; and organizations to effect systemwide changes to improve programs of care. The practice may include prescriptive privileges. (4) “Certified nurse practitioner” is an advanced practice nurse utilizing independent knowledge of physical assessment, diagnosis, and management of health care and illnesses. The practice includes prescriptive

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privileges. Certified nurse practitioners are members of the healthcare delivery system practicing in areas including, but not limited to: family practice, pediatrics, adult health care, geriatrics, and women's health care in primary, acute, long-term, and critical-care settings in healthcare facilities and the community. Certified nurse practitioners may be recognized as the primary-care provider or acute-care provider of record. (5) “Certified registered nurse anesthesia’’ means providing certain health care services in collaboration with anesthesiologists, licensed physicians or licensed dentists, in accordance with RIGL § 5-31.1-1(16) and Chapter 5-34.2, which requires substantial specialized knowledge, judgment and skill related to the administration of anesthesia, including pre-operative and post-operative assessment of patients; administering anesthetics; monitoring patients during anesthesia; management of fluid in intravenous therapy and management of respiratory care.

(6) ”Psychiatric and mental health nurse clinical specialist” is a certified clinical nurse specialist working in the population foci of psychiatric/mental health as an Advanced Practice Registered Nurse utilizing independent knowledge in psychiatric mental health assessment, diagnosis, health promotion, psychotherapeutic modalities and management of mental health and illnesses. The practice may include prescriptive privileges within their scope of practice. The practice may also include consultation and education.

(7) ”Certified Nurse-Midwife “(CNM) means a person who has successfully completed an accredited educational program in midwifery, holds a current certification as a nurse midwife by the American Midwifery Certification Board (AMCB), and is licensed to practice midwifery in Rhode Island. BCBSRI does not credential Certified Midwife (CM) or Certified Professional Midwife (CPM).

Physician Assistants According to TITLE 5 Businesses and Professions CHAPTER 5-5, Physician Assistants, SECTION: 5-54-8, Permitted healthcare practices by physician assistants:

Physician assistants shall practice in collaboration with physicians. A physician assistant may provide any medical or surgical services that are within the physician assistant's skills, education, and training. Whenever any provision of general or public law or regulation requires a signature, certification, stamp, verification, affidavit, or endorsement by a physician, it shall be deemed to include a signature, certification, stamp, verification, affidavit, or endorsement by a physician assistant. Physician assistants may perform those duties and responsibilities consistent with the limitations of this section, including prescribing, administering, procuring, and dispensing of drugs and medical devices. Physician assistants may request, receive, sign for, and distribute professional samples of drugs and medical devices to patients only within the limitations of this section. Notwithstanding any other provisions of law, a physician assistant may provide medical and surgical services when those services are rendered in collaboration with a licensed physician

Practice of Midwifery The license to practice midwifery authorizes the holder to practice the independent management of cases of normal childbirth, including prenatal, intrapartum, postpartum, and normal newborn care, and well woman care including the management of common health problems that provides for consultation, collaborative management, or referral as indicated by the health status of the client in accordance with standards established by the American College of Nurse-Midwives and the National Association of Certified Professional Midwives referenced in these Regulations.

Certified Registered Nurse First Assistants The following is from Rhode Island General Laws Title 27
§ 27-20-35.1 Third party reimbursement for services of registered nurse first assistants. (a) Every individual or group health insurance contract, plan or policy delivered, issued or renewed by an insurer or nonprofit or for profit health service corporation which provides benefits to individual subscribers and

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members within the state, or to all group members having a principal place of employment within the state, shall provide benefits for services rendered by a registered nurse first assistant, provided, that the following conditions are met:
(1) The registered nurse first assistant provides certain health care services under the supervision of a licensed physician; is currently licensed as a registered nurse in Rhode Island; has successfully completed a course in preparing the registered nurse as a first assistant in accordance with the Association of Operating Room Nurses core curriculum guide for the registered nurse first assistant and includes a minimum of one academic year in a college or university with didactic instruction and clinical internship programs; and is certified in perioperative nursing by the Certification Board of Perioperative Nursing (minimum of two years perioperative experience);
(2) The policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the state; and
(3) The registered nurse first assistant is not a salaried employee of the licensed hospital or facility for which the nonprofit hospital service corporation has an alternative contractual relationship to fund the services of a registered nurse first assistant.
(b) It remains within the sole discretion of the nonprofit medical service corporation as to which registered nurse first assistant in surgery it contracts with. Reimbursement is provided according to the respective principles and policies of the nonprofit medical service corporation: provided, that no nonprofit medical service corporation is required to provide direct reimbursement, or pay for duplicative services actually rendered by a registered nurse first assistant and any other health care provider. Nothing contained in this section precludes the nonprofit medical service corporations from conducting managed care, medical necessity or utilization review

CMS guidelines regarding incident to services
“Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable covered services benefits/coverage.

CODING Not applicable

RELATED POLICIES Coding and Payment Guidelines

PUBLISHED Provider Update, April 2023 Provider Update, September 2022 Provider Update, February 2020 Provider Update, July 2017 Provider Update, January 2017 Provider Update, August 2011

REFERENCES

1. Rhode Island General Laws§ 5-34-3 State of Rhode Island and Providence Plantations, Department of Health Rules and Regulations, http://webserver.rilegislature.gov//Statutes/TITLE5/5-34/5-34-3.htm
2. Rhode Island General Laws § 5-54-8, Title 5 Businesses and Professions, Chapter 54 Physician Assistants http://webserver.rilin.state.ri.us/Statutes/TITLE5/5-54/5-54- 8.HTM#:~:text=R.I.%20Gen.%20Laws%20%C2%A7%205-54-8%20%C2%A7,5-54- 8.%20Permitted%20healthcare%20practices%20by%20physician%20assistants

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

3. State of Rhode Island General Laws Title 27 Insurance: http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20-35.1.HTM
4. Rhode Island Department of State, Department of Health, Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs Amended January 2022 : https://rules.sos.ri.gov/regulations/part/216-40-05-3
5. Rhode Island Department of State, Department of Health, Licensure of Physician Assistants
   https://rules.sos.ri.gov/regulations/part/216-40-05-24
6. Rhode Island Department of State, Department of Health, Professional Licensing – Midwives https://rules.sos.ri.gov/regulations/part/216-40-05-23
7. Prior to 1998 - Definition and Registration of Mid-Level Practitioners (usdoj.gov)

8. Bishop, Catherine, DNP,NP,AOCNP; Advanced Practitioners Are Not Mid-Level Providers:

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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