Incident To Services

Policy No: 148
Originally Created: 01/01/2023
Section: Administrative
Last Reviewed: 03/01/2024
Last Revised: 03/01/2023
Approved: 03/14/2024
Effective: 01/01/2024
Policy applies to: Group and Individual

This policy applies only to physicians and other qualified health care professionals.

Associate
Is registered with their appropriate state licensure board and on a formal track/program for licensure.

Behavioral Health Services
A variety of treatment techniques in which a physician or other qualified health care provider helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns, and contributing/exacerbating factors. This treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills.

Immediately Available
Immediately Available - meaning "without delay." The supervising physician/or other eligible practitioner is in the office suite or patient's home, readily available and without delay, to assist and take over the care as necessary.

Incident To
Those services that are furnished by a Non-Physician Practitioner (NPP) provider incident to physician or other eligible practitioner’s professional services in the physician’s or other eligible practitioner’s office (whether located in a separate office suite or within an institution) or in a patient’s home.

Non-Physician Practitioner (NPP)
A provider that practices either in collaboration with or under the supervision of a physician or other eligible health care practitioner.

Palliative Care
Specialized medical care for people with serious illness. Providing patients with relief from the symptoms, pain, and stress of a serious illness, regardless of diagnosis.

Supervising physician or other eligible health care practitioner
Credentialed and licensed provider that engages in supervision of an associate.

Generally, our health plan requires that all licensed and credentialed providers bill for all services they perform under their own name. A licensed provider may not submit claims for services of and/or on behalf of (i.e., incident to) another provider (e.g., NPP).

However, incident to services are acceptable to be billed for palliative care services and behavioral health services in the appropriate place of service.

Regarding palliative care services:

Qualifications for providing incident to services include, but are not limited to:

• Services are part of the member’s normal course of treatment.
• The physician or other eligible health care practitioner personally performs the initial service and remains actively involved in the course of treatment and must provide direct supervision and/or be immediately available.
• The member’s medical record should document the requirements for 'incident to' services.
• NPP must perform health services under direct supervision.
• NPP must be an employee or independent contractor of a physician group if service is performed in a satellite office.
• Service settings include in an office, patient’s home, office within a skilled nursing facility (SNF) patient setting.
• The incident to service is submitted under the physician or other eligible health care practitioner’s name and identification.
• For a service to be considered for payment under the incident to billing, the modifier SA must be appended to the line. Only claims with the required SA modifier will be considered eligible for incident to billing.

The NPP provides an integral aspect of care as a commonly rendered service. NPP types may provide incident to services that are within the scope of practice as authorized under State law. Furthermore, a NPP cannot supervise another NPP.

Regarding behavioral health services:

Requirements for general supervision for providing incident to services must be met as listed below:

• Services are part of the member’s normal course of treatment.
• Supervising physician or other eligible health care practitioner monitors the course of treatment and must be available by telephone or telehealth for consultation as needed.
• Supervising physician or other eligible health care practitioner must be in the same provider group as the Associate staff.
• Documentation of the patient’s overall treatment must be reviewed by the supervising physician or other eligible health care practitioner.
• Documentation that the supervising physician or other eligible health care practitioner is meeting with associate staff to supervise/monitor care.
• For a service to be considered for payment under the incident to billing, the modifier SA must be appended to the line. Only claims with the required SA modifier will be considered eligible for incident to billing.
• The incident to service is submitted under the physician or other eligible health care practitioner’s name and identification.
• The supervising physician/provider must have an education level equal to or higher than the associate.
• Supervising physician/provider include Clinical Mental Health Counselor (CMHC), Licensed Clinical Professional Counselor (LCPC), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Licensed Psychologist (PsyD), Licensed Psychiatrist (MD), subject to state licensing requirements.

Associate staff eligible to bill for behavioral health as incident to are listed below:

• All Master’s prepared behavioral health clinicians who are registered with their appropriate state licensure board and on a formal track/program for licensure.
• All Doctorate prepared behavioral health clinicians who are registered with their appropriate state licensure board and on a formal track/program for licensure.

• Licensed Masters Social Worker LMSWs, subject to state licensing requirements.

The associate staff provides an integral aspect of care as a commonly rendered service. Associate staff may provide incident to services that are within the scope of practice as authorized under State law. Furthermore, an associate staff cannot supervise another associate staff or perform services independently in their own practice.

Centers for Medicare & Medicaid Services (CMS), 2016. 'Incident To' Services. MLN Matters Number: SE0441.

Centers for Medicare & Medicaid Services (CMS), 2022. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services. Section 60.4 – Services Incident to a Physician's Service to Homebound Patients Under General Physician Supervision.

Claims and Payment; Claims Submission

Palliative Care