Basic Rules of Coverage
Medicare Part B covers services by non-physician practitioners in all settings, in both urban and rural areas, if the following conditions are met:
â€¢The services would be covered as physician services if furnished by a physician
â€¢The practitioner is legally authorized to perform the services in the state where they are performed. These represent minimal Medicare rules; State laws may be more restrictive:
◦Physician Assistants must have graduated from an approved physician assistant educational program and passed the certifying examination of the National Commission on Certification of Physician Assistants
◦Nurse practitioners must:
â€¢Be authorized by the State to practice as a nurse practitioner and be certified by a recognized national certifying body
â€¢Have a Medicare billing number as a NP by December 31, 2000
â€¢Be authorized by the state to practice as a nurse practitioner and be certified by a recognized national certifying body if after January 1, 2001, applies for a billing number for the first time
â€¢Be authorized by the state to practice as a nurse practitioner and be certified by a recognized national certifying body and possess a masterâ€™s degree in nursing if after January 1, 2003, applies for a billing number for the first time
◦Clinical Nurse Specialists must have a masterâ€™s degree in a defined area of nursing and be certified by the American Nurse Credentialing Center
◦Certified Nurse-Midwives must have completed an accredited course of study and be certified by the American College of Nurse-Midwives or the American College of Nurse Midwives Certification Council
â€¢Medicare does not otherwise preclude the services from coverage
â€¢Within the scope of state law and CMS guidelines relating to 'incident to' services, services 'incident to' the nonphysician practitionerâ€™s services are covered if the services:
1.Would be covered if furnished by a physician or incident to a physician
2.Are commonly furnished in office without charge or included in bill
3.Are incidental to but an integral part of the professional services
4.Are performed with the nonphysician practitioner physically present and immediately available
â€¢The scope of practice for these nonphysician practitioners is based on State law. Palmetto GBA's role is not to adjudicate scope of practice. Accordingly, unless a service is excluded from the provider's scope of practice based on state law, Medicare will consider all services performed by these specialties for payment, provided that medical necessity for the service(s) rendered and other requirements are met.
For additional information regarding Medicare coverage of services by non-physician Practitioners, refer to the following Internet sites:
◦Physician Assistant services:
◦CMS Medicare Benefit Policy Manual (PDF, 2.35 MB), (Pub. 100-02), chapter 15, section 190
◦CMS Medicare Claims Processing Manual (PDF, 902 KB), (Pub. 100-04), chapter 12, section 110
◦Nurse practitioner, clinical nurse midwife, and clinical nurse specialist services:
◦CMS Medicare Benefit Policy Manual (PDF, 2.35 MB), (Pub. 100-02), chapter 15, sections 180, 200, and 210
◦CMS Medicare Claims Processing Manual (PDF, 902 KB), (Pub. 100-04), chapter 12, section 120
Web sites and contact information related to state boards and licensing:
State Advance Practice Nurses Physician Assistants
American Samoa www.nurse.org/as-index.shtml Not available
California www.rn.ca.gov/applicants/ad-pract.shtml www.pac.ca.gov/
Guam Maria Isabel Salomon, DNS, RN, President (Term ends 12/2009)
Glynis S. Almonte, BSN, RN, Executive Director
P.O. Box CG
Hagatna, GUAM 96932
Phone: (671) 477-6877
Fax: (671) 477-6877
Board of Medical Examiners
Health Professionals Licensing Office
651 Legacy Square Commercial Complex,
South Route 10, Suite 9,
Margilao, GU 96913
Hawaii www.hawaiinurses.org/ www.state.hi.us/dcca/areas/pvl/boards/medical
Ohio www.nursing.ohio.gov/ http://med.ohio.gov/medpa.htm
Nevada www.nursingboard.state.nv.us/ http://medboard.nv.gov/
Northern Mariana Islands http://www.board-of-nursing.com/mari...of-nursing.php Medical Professional Licensing Board
PO Box 501458
Saipan, MP 96950
South Carolina www.llr.state.sc.us/pol/nursing/
West Virginia www.wvnurses.org/ www.wvdhhr.org/wvbom/
Private Contracting With Medicare Beneficiaries (Opting Out)
Effective January 1, 1998, Section 4507 of the Balanced Budget Act of 1997 (BBA) permitted certain physicians and practitioners (under the limited definition for this purpose) to privately contract with Medicare beneficiaries if the physician or practitioner files an affidavit with Medicare opting out of Medicare for two years. Not all physicians and practitioners are eligible to opt out.
The following can 'opt out' of Medicare under this provision:
â€¢For purposes of this provision, physicians include:
◦Doctors of medicine, doctors of osteopathy, doctors of dental surgery or of dental medicine, doctors of podiatric medicine and doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, medicine or surgery by the state in which such function or action is performed. No other physicians may opt out.
â€¢Practitioners permitted to opt out are physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), certified nurse midwives (CNMs), clinical psychologists, clinical social workers (CSWs), registered dieticians and nutrition professionals. .
â€¢The opt out law does not define 'physician' to include chiropractors, therefore, chiropractors may not opt out of Medicare and provide services under private contract. Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not with the 'opt out' lawâ€™s definition of either a 'physician' or 'practitioner.'
The following provisions apply:
â€¢The physician/practitioner agrees not to file claims to Medicare or any other organization which receives reimbursement from Medicare - unless the service is for emergency or urgent care which would require the use of HCPCS modifier GJ (Opt -Out Physician or Practitioner Emergency or Urgent Service)
â€¢Contracts must be signed by both parties before any item or service is provided (pursuant to the contract)
â€¢The contract must clearly indicate to the beneficiary that by signing the contract he/she:
◦Agrees not to submit a claim to Medicare
◦Agrees to pay the provider for the service
◦Agrees to pay 'full-fee' for the service with no limits on amount
◦Acknowledges that supplemental insurance may not make payment because Medicare will not make payment
◦Acknowledges that the beneficiary can choose to go to another physician and have Medicare reimburse for the services. The contract must clearly indicate whether the physician is excluded from Medicare.
◦The physician must file an affidavit with the Medicare contractor acknowledging that he/she will not file any claims with Medicare for two years beginning on the date the affidavit was signed
◦A provider who 'opts out' must opt out with all Medicare beneficiaries. They cannot private contract with some beneficiaries and bill Medicare for others.
◦If one member of a provider group 'opts out,' all members of that group must opt out as well
If the provider violates any of these provisions, he/she will not be able to enter into any additional private contracts during the two-year period, nor could they count on any reimbursement from Medicare for their services.
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