Reminder: Submit claims only for services you personally provide or directly supervise

As a professional provider, you may submit claims only for services you personally provide or directly supervise.

Professional providers may not submit claims for services provided by peers who are not registered or not credentialed by BCBSM. This includes peers who are awaiting program affiliation or who have been denied affiliation or disaffiliated from BCBSM networks or programs.

According to Section 3.6 of the BCBSM TRUST Practitioner Agreement:

“Trust practitioner certifies that all services billed or reported by Trust Practitioner are performed personally by Trust Practitioner or under his/her direct and personal supervision, as defined by BCBSM, and in his/her presence except as otherwise authorized and communicated by BCBSM.”

The authorized and published exceptions to this requirement are:

• Physicians may bill for covered services routinely performed by qualified non-physician office staff. Examples include: injections, infusions, application of dressings, etc.

• Physicians may bill for services predominantly provided by physician assistants or certified nurse practitioners if the requirements for “indirect billing” by the PA or CNP are met. These are circumstances where the physician has substantial and timely involvement in the services delivered.

• Claims may be submitted under the NPI of a network physician for services provided by other qualified physicians when Medicare locum tenens rules apply.

• Physicians may bill for physical therapy services provided in the office by a licensed physical therapist or by a physical therapy assistant working under the supervision of a licensed physical therapist. In addition, physicians may bill for occupational therapy services provided in the office by a licensed occupational therapist or by an occupational therapy assistant working under the supervision of a licensed occupational therapist. BCBSM discourages regular use of this method of billing for physical therapy and occupational therapy services and strongly encourages registration and direct billing by all physical and occupational therapists.

• Physicians who provide imaging services in the office may bill for the “full’ service, including interpretation of the study, and may sub-contract the interpretation of the study to a qualified physician. In this instance, the sub-contracted or interpreting physician may not submit claims to BCBSM for these services.

Violation of these policies may result in cancellation of BCBSM provider agreements. On audit, we may recover any payments made when these policies were not followed.