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  • Credentialing > Physician Assistant Services

    The professional services of a physician assistant (PA) may be covered in network if he or she is contracted, meets qualification for PAs 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.

    Note: No separate payment will be made to the physician assistant 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 PAs

    A PA must be licensed by the state to practice as a PA and meet one of following two qualifications:

    • Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs [CAAHEP] and the Committee on Allied Health Education and Accreditation [CAHEA])
    • Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA)

      Covered Services

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

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

        Types of PA Services That May Be Covered

        PAs may provide services billed under all levels of CPT evaluation and management codes, and diagnostic tests, if provided under the general supervision of a physician. Examples of services PAs may provide include services traditionally reserved for physicians, such as examinations (including the initial preventive physical examination), minor surgery, setting casts for simple fractures, interpreting X-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. In general, PAs are paid for covered services at 85 percent of what a physician is paid.

        Services Otherwise Excluded From Coverage

        PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by state law to perform them.

        Physician Supervision

        The PA’s physician supervisor (or a physician designated by the supervising physician or employer as provided under state law or regulations) is primarily responsible for the overall direction and management of the PA’s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present when a service is provided by the PA to a patient and may be contacted by telephone, if necessary, unless state law or regulations require otherwise.

        Sending Your Application

        To submit a request for PA credentialing, print and complete a Credentialing Application Addendum for Registered Physician Assistant form, and mail to the applicable address below.

        For New York City, Nassau county and Suffolk county, as well as New Jersey and Connecticut applicants, please send your completed application and agreements to:

        EmblemHealth
        55 Water Street
        New York, NY 10041
        Attn: Physician Contracting, 7th floor

        For all other counties in New York State, as well as all other out-of-state applicants, please send your completed application and agreements to:

        EmblemHealth
        5015 Campuswood Drive
        East Syracuse, NY 13057
        Attn: Physician Contracting

        Note: All applications must include the signed agreement for the networks you would like to join.

         

         

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        Glossary terms found on this page:

        An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

        Services that have been approved for payment based on a review of EmblemHealth's policies.

        A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.

        An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

        A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

        A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

        An individual other than the subscriber who is eligible to receive health care services under the member's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.

        A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

        A test or procedure ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services.

        Specific conditions or circumstances that are not covered under the benefit agreement or Certificate of Insurance. It is very important to consult the benefit contract to understand what services are not covered benefits.

        A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

        An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

        • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
        • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
        • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
        • Maintains medical records for all patients
        • Has a requirement that every patient be under the care of a member of the medical staff
        • Provides 24-hour patient services
        • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

        A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.

        Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

        Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

        The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

        A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

        • Doctor of medicine
        • Doctor of osteopathy
        • Dentist
        • Chiropractor
        • Doctor of podiatric medicine
        • Physical therapist
        • Nurse midwife
        • Certified and registered psychologist
        • Certified and qualified social worker
        • Optometrist
        • Nurse anesthetist
        • Speech-language pathologist
        • Audiologist
        • Clinical laboratory
        • Screening center
        • General hospital
        • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

        A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

        A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services. Also called a SNF.

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