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Covered Providers


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/June 2012
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, including service extenders and other clinical staff 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 contracting medical service providers. Covered providers in the group/member contracts may vary, but generally, covered providers include but are not limited to:

  • Advance practice nurse (certified nurse midwife, clinical nurse specialist, nurse practitioner)
  • Alcoholism or substance abuse treatment facility
  • Ambulance transportation service
  • Ambulatory surgical facility (surgery center)
  • Audiologist
  • Certified speech therapist
  • Chiropractic physician
  • Clinical psychologist
  • Dentist/denturist
  • Diagnostic imaging provider
  • Durable medical equipment supplier
  • Electroencephalogram (EEG) provider
  • Freestanding diabetes facility
  • Freestanding dialysis facility
  • Home health agency
  • Home intravenous therapy company
  • Hospice
  • Independent laboratory
  • Licensed clinical professional counselor (LCPC)
  • Licensed clinical social worker (LCSW)
  • Licensed marriage and family therapist (LMFT)
  • Licensed general hospital
  • Licensed rehabilitation hospital
  • Lithotripsy provider
  • Optometrist/optician
  • Occupational therapist
  • Physical therapist
  • Physician
  • Podiatrist
  • Prosthetic and orthotic supplier
  • Psychiatric hospital
  • Registered dietician
  • Registered nurse anesthetist
  • Skilled nursing facility

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 Extender
Service extenders support covered providers in their practice and render separately identifiable services for covered providers. Service extenders must have an approved application on file, receive supervision from a covered provider and have their own provider number designating them as the performing provider. 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 the like, but are not eligible for separate reimbursement. Other clinical staff includes, but is not limited to:

  • Associate counselor BS (ISAS, LSAC)
  • Certified medical 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)
  • Nurses aid
  • Paramedic
  • Pastoral counselor
  • Phlebotomist
  • Radiology technician
  • Registered nurse (RN)
  • Speech language pathology aide
  • Surgical scrub technician
  • Registered nurse first assistant (RNFA)

Non-Covered Provider (for Blue Cross of Idaho policy holders)
Medical service providers who are not eligible for reimbursement under Blue Cross of Idaho's policies 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
  • 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-contracted providers - meet Blue Cross of Idaho licensing and/or accreditation standards but have not a 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 non-covered provider services as non-covered and the charges become the member's liability.


Policy History

Date Action Reason
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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