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Physician Extender Guidelines

A physician extender is a specially trained, certified and licensed provider who renders medical services within the scope of his/her license. Blue Cross and Blue Shield of Alabama recognizes the following physician extenders as eligible network participants:

Many groups provide coverage for the services of a CRNP, CNM, CRNA, PA or PA/SA; however, providers are encouraged to verify a patient's eligibility and benefits before rendering services. Members may not be eligible for reimbursement for services provided by a non-participating CRNP, CNM, CRNA, PA or PA/SA or services may be reimbursed at the out-of-network benefit level.

For evaluation and management (E&M) services, Blue Cross requires claims to be billed under the name and National Provider Identifier (NPI) of the provider who physically evaluates the patient to collect or confirm the patient’s History of Present Illness (HPI). The provider who is physically conducting or affirming the HPI and performing an in-person examination can bill for the Evaluation and Management (E&M) service. This work is not relegated to ancillary staff. The Review of Systems (ROS) and Past/Family/Social/History (PFSH) may be recorded by ancillary staff or on a form completed by the patient. In certain instances, an office or triage nurse may document pertinent information regarding the chief complaint, but this information should be treated as preliminary information. The billing provider of the E&M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail. The information the billing provider records as the HPI needs to be their own synopsis of all of the HPI gathered.

Additionally, Blue Cross does not recognize "incident to" billing. Under no circumstances should services performed solely by a CRNP, CNM, CRNA, PA or PA/SA be billed under a physician's name and NPI.

Eligibility and benefits can be verified through your practice management software system or through ProviderAccess on our website, AlabamaBlue.com/Providers.