General
Chapter 1
Section 6
Reimbursement
Of Physician Assistants (PAs), Nurse Practitioners (NPs), And Certified
Psychiatric Nurse Specialists (CPNSs)
Issue Date: July 9, 1990
Revision:
1.0 APPLICABILITY
This policy is mandatory for
reimbursement of services provided by either network or non-network
providers. However, alternative network reimbursement methodologies
are permitted when approved by the Defense Health Agency (DHA) and
specifically included in the network provider agreement.
2.0 ISSUE
How are PA, NP, and CPNS services
to be reimbursed?
3.0 POLICY
3.1 The allowable
charge for the services of the above listed providers may not exceed
85% of the allowable charge for a comparable service rendered by
a physician. The employing physician of a PA must be an authorized
TRICARE provider.
3.1.1 When
the employing physician of a PA is not participating in a TRICARE
reimbursement plan at less than the allowable charge determined
under the provisions of
Section 1, the allowable charge for the PA
service may not exceed 85% of the allowable charge for the physician
calculated in accordance with these provisions. When the PA and
the physician perform component services of a procedure other than
assistant-at-surgery (e.g., home, office or hospital visit components),
the allowable charge for the procedure (to include both the services
of the physician and PA) may not exceed the allowable charge for
the procedure rendered by a physician.
3.1.2 When
the employing physician is participating in a TRICARE reimbursement
plan at less than the allowable charge as calculated in
paragraph 3.1.1,
the allowable charge for the PA service may not exceed 85% of the
reduced allowable charge for the physician unless the reimbursement
plan has specifically included use of PAs in the negotiated rates.
3.2 For services provided on or
after July 27, 2012, the allowable charge for PA services performed as
an assistant-at-surgery may not exceed 85% of the allowable charge
for a physician serving as an assistant surgeon when authorized
as TRICARE benefits in accordance with the provisions of
32 CFR 199.4(c)(3)(iii).
3.3 The allowable charge for NP
services performed as an assistant-at-surgery may not exceed 85% of
the allowable charge for a physician serving as an assistant surgeon
when authorized as TRICARE benefits in accordance with the provisions
of
32 CFR 199.4(c)(3)(iii).
3.4 The procedure or service performed
by the PA is billed by the supervising or employing physician, billing
it as a separately identified line item (e.g., PA Office Visit)
and accompanied by the assigned PA provider number.
3.5 The procedure or service performed
by the NP or CPNS is billed by the NP or CPNS. Unlike a PA, a NP
or CPNS can bill on their own behalf. Like the PA, the NP or CPNS
shall bill using an assigned NP provider number.
4.0 EFFECTIVE DATES
4.1 Reimbursement
of PA services is effective for services rendered on or after July
1, 1990.
4.2 Reimbursement of NP services
as stated above is effective for services rendered on or after September
1, 2003.
4.3 Reimbursement
of CPNS services shall be 85% of the allowable amounts for physicians effective
for services rendered on or after June 1, 2007.
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