Advanced Practice Professional (APP) billing

Office-based services

Nurse Practitioners (NP), Physician Assistants (PA) and Certified Nurse Midwives (CNM) must be contracted and credentialed to bill directly for services. To contract with us and start the credentialing process for your APP:

  1. Log into your prism account
  2. Click the Enrollments & Requests tab
  3. Choose the appropriate option for your enrollment request

If you choose not to credential your providers, then we require you to bill claims under the Supervising Physician.  

Surgical assists and facility rounding

APPs don’t need to be credentialed if they’re assisting in surgery or rounding in a facility, but they must be enrolled in our system to process and pay claims. To enroll your APP:

  1. Log into your prism account
  2. Click on the Enrollments & Requests tab
  3. Choose the appropriate option for your enrollment request

All surgical assists must use HCPCS Level II modifier -AS, a non-physician assistant at surgery. This includes PA, CNS, CRNFA, RNFA, NP, DDS, DMD, and surgical technician provider types, subject to contract eligibility.

See details about modifiers 80 and 82.

Reimbursement

Most services are reimbursed at 85% of the professional fee schedule. Medicaid is exempt from this 85% mid-level (APP) reduction.

Some services may be paid at the 100% of the physician fee schedule, if you are contracted to provide them:

  • Anesthesia
  • Labs, including venipuncture and radiology
  • Immunizations, vaccines and toxoids
  • Injectables and supplies and ancillary services
  • Services provided by APPs who are credentialed as Primary Care providers
  • Services provided by APPs who are credentialed as CNMs