Incident To Services - Medicare Advantage

Policy No: 148
Originally Created: 01/01/2023
Section: Administrative
Last Reviewed: 03/01/2024
Last Revised: 03/01/2024
Approved: 03/14/2024
Effective Date: 01/01/2024
Policy applies to: Medicare Advantage

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

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.

General Supervision
The service is furnished under the physician's (or other practitioner's) overall direction and control, but the physician's (or other practitioner's) presence is not required during the performance of the service.

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.

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 patients and behavioral health services in the appropriate place of service.

The Health Plan follows CMS guidelines for incident to services rendered for palliative care and behavioral health.

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.
• 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 equal or higher-level license than the associate.
• Supervising physician/provider must be a Licensed Psychologist (PsyD), Licensed Psychiatrist (MD), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Counselor (LPC), subject to state licensing requirements.

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

• Eligible Associates must be Clinical Mental Health Counselor (CMHC), Licensed Clinical Professional Counselor (LCPC), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), subject to state licensing requirements.

We will follow CMS guidelines for providers who can render services for incident to billing. CMS has considered reducing barriers to getting mental health access and make greater use of behavioral health services and as such have included licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs) as providers that can render these services, via incident to billing. Therefore, these providers may not bill direct.

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

Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule

Strengthening Behavioral Health Care for People with Medicare

Public inspection Federal Register

Palliative Care