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Covered Providers


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/July 2014
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Covered Providers

Blue Cross of Idaho only pays for services rendered by covered providers, and service extenders affiliated with a covered provider. All providers and facilities listed in this policy must perform the service within the scope of the license to provide benefits and be licensed and/or registered with the state where the services occur.

All providers fall into one of the four following categories:

  1. Covered providers
  2. Service extenders
  3. Other clinic staff
  4. Non-covered providers

Covered Providers

Included with each Blue Cross of Idaho group and individual member contract is a list of covered medical service providers. In order to be recognized as a covered provider, each provider must maintain certain levels of licensure and/or certification. In addition to the licensure/certification requirements listed below, the provider packet links on the provider page of bcidaho.com detail the specific requirements, by provider type. While, covered providers in the group/member contracts may vary, generally covered providers include:

  • Advance practice nurse (certified nurse midwife, clinical nurse specialist, nurse practitioner) - state licensed
  • Alcoholism or substance abuse treatment facility - The Joint Commission (TJC) or Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Ambulance transportation service - state licensed
  • Ambulatory surgical facility (surgery center) - Medicare certification
  • Audiologist - state licensed
  • Certified speech therapist - state licensed
  • Chiropractic physician - state licensed
  • Clinical psychologist - state licensed
  • Dentist/denturist - state licensed
  • Diagnostic imaging provider - Medicare certified
  • Durable medical equipment supplier - Medicare certified
  • Electroencephalogram (EEG) provider - must subcontract through the hospital
  • Freestanding diabetes facility - person or entity accredited by the American Diabetes Association
  • Freestanding dialysis facility - Medicare certified or The Joint Commission (TJC) accredited
  • Home health agency - Medicare certified
  • Home Intravenous therapy company - Medicare certified
  • Hospice - Medicare certified or hospital based
  • Independent laboratory Medicare and Clinical Laboratory Improvement Amendment (CLIA) certified
  • Licensed clinical professional counselor (LCPC) - state licensed
  • Licensed clinical social worker (LCSW) - state licensed
  • Licensed marriage and family therapist (LMFT) - state licensed
  • Licensed general hospital - The Joint Commission on Accreditation of Rehabilitation Facilities (CARF) accredited
  • Lithotripsy provider - must subcontract through hospital
  • Optometrist/optician - state licensed
  • Occupational therapist - state licensed
  • Physical therapist - state licensed
  • Physician - state licensed
  • Podiatrist - state licensed
  • Prosthetic and orthotic supplier - Medicare certified
  • Psychiatric hospital - The Joint Commission (TJC) or American Osteopathic Association (AOA)
  • Registered dietician - State licensed
  • Skilled nursing facility - Idaho Department of Health and Welfare licensed

Please note: We do not contract with resident physicians. The supervising physician should submit claims with his or her NPI number for services rendered by resident physicians.

Service Extenders

Service extenders support covered providers in their practice and render separately identifiable services. While service extenders always act under the supervision of a covered provider, all service extenders must apply and be approved with their own provider number designating them as the performing provider. When submitting claims to Blue Cross of Idaho, the service extender will represent him/herself on the claim, however Blue Cross of Idaho reimburses the supervising provider or the clinic/business employing the service extender. Service extenders include:

  • Physician assistant (PA)
  • Non-physician assistant - certified surgical assist or tech (CSA or CST), certified orthopedic technologist (COT), certified registered nurse first assist (CRNFA), orthopedic physician assistant - certified )OPA-C)

Requirements for Behavioral Health Extenders -see PAP900

Other Clinical Staff

Other clinical staff provides support services to covered providers during office visits, surgical procedures and other procedures, but are not eligible for separate reimbursement. Services provided by these individuals are represented in and reimbursed under the services billed by the covered provider. Other clinical staff includes:

  • Associate counselor BS (ISAS, LSAC)
  • Certified medical assistant
  • Certified nursing assistant
  • Certified occupational therapy assistant - licensed (COTA-L)
  • Chemical and alcohol dependency counselor (CADC)
  • Hearing aid fitter
  • Licensed practical nurse (LPN)
  • Licensed physical therapy assistant
  • Licensed social worker (LSW)
  • Paramedic
  • Pastoral counselor
  • Phlebotomist
  • Radiology technician
  • Registered nurse (RN)
  • Speech language pathology aide
  • Surgical scrub technician
  • Registered nurse first assistant (RNFA)

Non-covered Providers (for Blue Cross of Idaho policy holders)

Non-covered providers cannot be classified or recognized as other clinical staff and their services are not eligible. Non-covered providers include, but are not limited to:

  • Acupuncturist*
  • Any provider who is non-contracting and is required to be contracting to be covered under the group/members' policy
  • Any provider who is not licensed, certified or accredited as required to be a covered provider
  • Chiropractic assistant
  • Homeopath*
  • Massage therapist*
  • Naturopath*
  • Providers failing to meet Blue Cross of Idaho's credentialing criteria or hold no contract with Blue Cross of Idaho. Services are considered non-covered and no payment is made to either the provider or member

*Some Blue Cross of Idaho policies may allow these provider types.

Services must be billed by the provider who performs the services.

Definitions

Contracted providers - meet Blue Cross of Idaho licensing, accreditation and/or credentialing criteria and have a signed contract with Blue Cross of Idaho. Blue Cross of Idaho pays contracting providers directly for covered services.

Non-contracting providers - meet Blue Cross of Idaho licensing and/or accreditation standards but have not signed a contract with Blue Cross of Idaho. Blue Cross of Idaho pays our members directly for covered services provided by non-contracting providers.

Non-covered providers - do not meet Blue Cross of Idaho's licensing and/or accreditation standards. Blue Cross of Idaho denies services provided by non-covered providers and the charges become the members' liability.


Policy History

Date Action Reason
July 2014 Revised Added requirements to covered providers, added Chiropractic Assistant to non-covered providers
June 2012 Revised Added language "Services must be billed by the provider who performs the services."
September 2011 Revised Added Licensed physical therapy assistant under Other Clinical Staff
April 2011 Revised Some Blue Cross of Idaho policies may allow these provider types
October 2010 Revised Added Registered Dietician as covered provider
April 2010 Revised Certified First Assistant (CFA) removed from covered provider list, was listed in error.
January 2010 Revised Link added to PAP900 and revisions to CADCs and LSWs
July 2009 Revised Chiropractic assistant removed
July 2009 Revised Added chiropractic assistant to "Other Clinical Staff"
March 2009 Revised Contracting/Non-contracting information added. LMSW added to Service Extenders. COTA-L and Speech
November 2008 Revised Language addition
August 2008 Revised Language clarification

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