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:

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 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:

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.