MIDWIFERY SERVICES
EmblemHealth requires midwives to have a collaborative relationship with a participating physician practicing obstetrics and gynecology. Participation midwives, or those applying for participation with EmblemHealth, must document this collaborative relationship and make this information available to their patients. Failure to comply with this directive may result in professional misconduct charges. Refer to nysed.gov for New York State Midwifery definitions and requirements.
LACTATION CONSULTANT SERVICES
EmblemHealth adopts policy guidance from the New York State Medicaid program to ensure appropriate designation of participating practitioners as breast feeding, education, and lactation counselors. Physicians, Nurse Practitioners, Midwives, Physician Assistants, and Registered Nurses seeking this credential must have the following minimum requirements, as defined in the EmblemHealth Credentialing Policy:
- Current and valid medical license
- Current and valid Drug Enforcement Administration (DEA) certificate (as applicable)
- Current malpractice coverage within acceptable limits
- Hospital privileges in good standing with a plan-contracted facility
- Acceptable work history
- Acceptable malpractice history
- Acceptable adverse action history
In addition to these minimum credentialing requirements, applicants must possess one of the following certifications:
- International Board-Certified Lactation Consultant (IBCLC)
- Certified Lactation Specialist (CLS)
- Certified Breastfeeding Specialist (CBS)
- Certified Lactation Counselor (CLC)
- Certified Lactation Educator (CLE)
- Certified Clinical Lactationist (CCL)
- Certified Breastfeeding Educator (CBE)
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 is made to the NP 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.
NP Qualification Requirements for Network Participation
An NP must meet all three of the following qualifications:
- Be a registered professional nurse 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 with 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:
Credentialing Application for NPs
Refer to the Join Our Network section of emblemhealth.com for the Credentialing Application for Nurse Practitioners.
Covered Services
Services are covered if they meet all four of the following criteria:
- Considered physician’s services otherwise 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 an MD/DO
- Not otherwise precluded from coverage because of statutory exclusions
Collaborative Relationship
NPs with over 3,600 hours of total practice experience are no longer required to maintain a collaborative agreement and practice protocols with the Department of Education. Instead, NPs must execute and maintain, at their practice location, an attestation form and documentation of their collaborative relationships with physicians and/or with a hospital.
- If the NP is opting to maintain a collaborative agreement, EmblemHealth accepts a written copy. In accordance with the Provider Agreement, the physician must be participating with EmblemHealth.
- If the NP is opting to not maintain a collaborative agreement, a completed copy of the New York State Education Department (NYSED) Collaborative Relationships Attestation Form is accepted to demonstrate option of practicing with collaborative relationships as defined by the NYSED.
If not prescribing or admitting, an explanation is needed to confirm coverage arrangements.
NPs 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, 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.
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 is made to the PA 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.
PA Qualification Requirements for Network Participation
A PA must be licensed by the state to practice as a PA and meet one of the 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)
Credentialing Application for PAs
Refer to the Join Our Network section of emblemhealth.com for the Credentialing Application for Physician Assistants.
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
PA Covered Services
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 involving an independent evaluation or treatment of the patient’s condition.
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 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.