Mountain State Medical Policy Bulletin
Section: Miscellaneous
Number: Z-27
Topic: Eligible Providers and Supervision Guidelines
Effective Date: January 4, 2010
Issued Date: January 4, 2010
Date Last Reviewed: 12/2009

General Policy Guidelines

Indications and Limitations of Coverage

Covered services must be personally performed by an eligible professional provider or performed under that provider's direct personal supervision (in accordance with the licensure, certification and/or employment criteria outlined below).

Eligible Professional Providers

Eligible professional providers are those providers duly licensed or certified and acting within their scope of license. They include:

  • Audiologists
  • Behavior Health Rehabilitation Agency Providers
  • Certified registered nurses
    - Certified registered nurse anesthetists
    - Certified registered nurse practitioners
    - Certified enterostomal therapy nurses
    - Certified community health nurses
    - Certified psychiatric mental health nurses
    - Certified clinical nurse specialists
  • Clinical laboratories
  • Dentists
  • Doctors of chiropractic
  • Doctors of medicine
  • Doctors of osteopathy
  • Licensed Clinical Social Workers
  • Marriage and Family Therapists
  • Nurse midwives
  • Occupational Therapists
  • Optometrists
  • Physical therapists
  • Podiatrists
  • Professional Counselors
  • Psychologists
  • Speech pathologists
  • Teachers of the hearing impaired

Eligible professional providers (as listed above) are not subject to these employment and/or supervision requirements.  Rather, they are governed by the state licensure or certification statutes and regulations applicable to their profession.

Supervision Guidelines

Mountain State Blue Cross Blue Shield will also reimburse covered services performed by licensed or certified health care practitioners, who are employed and personally supervised by eligible professional providers. For purposes of this guideline, "health care practitioner" is defined as a person who is licensed or certified to perform health-related services, but is not eligible for direct reimbursement from Mountain State Blue Cross Blue Shield. Examples of health care practitioners include Registered Nurses (R.N.s), Licensed Practical Nurses (L.P.N.s), and Physician Assistants (PAs).

“Supervision" means that the eligible professional provider must be immediately available physically or by electronic means (e.g. telephone, radio, telecommunications), in the event his or her assistance or oversight is required in the care of the patient. All supervision must be in accordance with the state licensure or certification requirements of the performing licensed or certified health care practitioner.

When providing care to the patient, the eligible professional provider has medical and legal responsibility for the services rendered. 

For reimbursement purposes, Mountain State Blue Cross Blue Shield requires that services reported for its members are either personally performed by the eligible professional provider or performed under such provider's personal supervision, as outlined in these guidelines.

Certain diagnostic tests have been identified that have extended technical components wherein the patient goes about normal daily activities while being monitored. These tests include holter monitoring (93224, 93228, 93230, and 93235), cardiac event monitoring (93268), and sleep studies (95807-95811). These procedures are performed under the physician's overall management and control, but the physician is not present for the duration of the test.

NOTE:
The technical component of diagnostic tests may be performed by technicians who have appropriate training and proficiency, as evidenced by licensure or certification from the appropriate state health or education department. In the absence of a state-level licensure or certification, the technician must be certified by the appropriate national credentialing body. In these cases, payment can be made to the provider who supervises and employs the licensed or certified technician.

There may be exceptions to this policy depending on the individual member's contract, and provider network rules.

See Medical Policy Bulletin Z-10 for information on Physician Assistants.

Procedure Codes


Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

FEP considers the following to be covered professionals when they perform services within the scope of the license or certification:

Physicians:

  • Doctors of Medicine (M.D.);
  • Doctors of Osteopathy (D.O.);
  • Doctors of Dental Surgery (D.D.S.);
  • Doctors of Medical Dentistry (D.M.D.); 
  • Doctors of Podiatric Medicine (D.P.M.); 
  • Doctors of Optometry (O.D.)

Other Covered, Licensed Health Care Professionals:

  • Acupuncturist (Acupuncture must be performed and billed by a physician or licensed acupuncturist)
  • Audiologist
  • Chiropractor/Doctor of Chiropractic (D.C.)
  • Clinical Psychologist
  • Clinical Social Worker
  • Diabetic Educator
  • Dietician
  • Independent Laboratory
  • Nurse Midwife
  • Nurse Practitioner/Clinical Specialist
  • Nursing School Administered Clinic
  • Nutritionist
  • Physical, Speech, and Occupational Therapist
  • Physician Assistant

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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[Version 013 of Z-27]
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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary

TermDescription

Employment Relationship

An employment relationship is established if all of the following criteria are sufficiently documented:

  • The employer has the power to hire and fire;
  • The employer has the power to direct the work done by the employee and has ultimate responsibility for the manner of his/her performance;
  • The employer has the duty to pay wages, fringe benefits, and establish the level of compensation;
  • The employer is personally responsible for withholding federal income tax and social security contributions and is personally responsible for making contributions for the employee and is personally responsible for insuring the employee's liability; and
  • There is no compensation received by any facility for the services of the employee during the period of employment by the employer.





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.