Credentialing > Nurse Practitioner Services
The professional services of a nurse practitioner (NP) may be covered in network if he or she is contracted, meets qualifications for NPs 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 nurse practitioner 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:
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 NP qualifications and 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
In general, NPs are paid for covered services at 85 percent of what a physician is paid.
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 would be performed by a physician in the absence of the NP. 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.
Sending Your Application
To submit a request for NP credentialing, print and complete a Credentialing Application Addendum for Nurse Practitioner 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:
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:
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.
Glossary terms found on this page:
The physician primarily responsible for the care of a patient during hospitalization. The physician is licensed, board-certified or board-eligible and qualified to practice in the area appropriate to treat the member's life-threatening or disabling condition or disease. The attending physician must be a network provider with EmblemHealth or one to which EmblemHealth has referred the member.
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.
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.
A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
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
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.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
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 type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.