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.

State-Designated Providers

State designation of providers will suffice for the EmblemHealth’s credentialing process. When contracting with NYS-designated providers, EmblemHealth will not separately credential individual staff members in their capacity as employees of these programs. EmblemHealth will still conduct program integrity reviews to ensure that provider staff are not disbarred from Medicaid or any other way excluded from Medicaid reimbursement. EmblemHealth will still collect and accept program integrity-related information from these providers, as required in the Medicaid Managed Care Model Contract, and will require that such providers not employ or contract with any employee, subcontractor, or agent who has been debarred or suspended by the federal or state government, or otherwise excluded from participation in the Medicare or Medicaid program.