EmblemHealth Coverage for Nurse Practitioner Services

Date Issued: 7/17/2013

EmblemHealth Coverage for Nurse Practitioner Services
The professional services of a nurse practitioner (NP) may be covered in network if he or she is contracted, meets the qualifications listed below and is legally authorized to provide services in the state where the services are performed.

Payments are allowed for assistant at surgery services and services provided in all areas and settings permitted under applicable state licensure laws. However, no separate payment will be made when a facility or other provider charges or is paid any amount for such professional services. A facility or other provider includes a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, ambulatory surgical center, community mental health center, rural health center or federally qualified health center.

Qualifications for NPs
An NP must meet all three of the following qualifications:

  • Be a registered professional nurse who is authorized by the state in which the services are provided to practice as an NP in accordance with state law
  • Be certified as an NP by a recognized national certifying body that has established standards for NPs
  • Possess a master’s degree in nursing

The following organizations are recognized national certifying bodies for NPs at the advanced practice level:

Covered Services 
Services are covered if they meet all four of the following criteria:

  • Considered physician’s services if provided by doctor of medicine or osteopathy (MD/DO)
  • Performed by a person who meets the definition of an NP, and the NP is legally authorized to perform the services in the state in which they are performed
  • Performed in collaboration with a MD/DO
  • Not otherwise precluded from coverage because of statutory exclusions

Nurse Practitioners as Attending Physicians<
Services provided by an NP that are medical in nature must be reasonable and necessary, be included in the plan of care, and in the absence of an NP would be performed by a physician. If the services performed by an NP can be performed by a registered nurse in the absence of a physician, they are not considered attending physician services and are not separately billable.

Services Otherwise Excluded From Coverage 
NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by state law to perform them. For example, the Medicare law excludes from coverage routine foot care and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body part. Therefore, these services are precluded from coverage even though they may be within an NP’s scope of practice under State law.

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