BCBSKS Billing Guidelines for Resident Physicians & Locum Tenens Providers: A Comprehensive Guide

Disclaimer: Blue Cross Blue Shield of Kansas (BCBSKS) policies and billing guidelines can change. This guide provides an overview based on current information; however, providers should always verify the latest requirements directly with BCBSKS or consult official documentation to ensure accurate and compliant billing practices.

BCBSKS Billing Guidelines for Non-Physician Practitioners and Resident Physicians in Kansas

Understanding the specific Kansas physician billing rules set by Blue Cross Blue Shield of Kansas (BCBSKS) for non-physician practitioners and resident physicians is crucial for accurate claim submission. This section outlines the general principles and detailed requirements for billing services provided by these professionals, ensuring compliance and proper reimbursement.

Billing for Non-Physicians (Excluding APRNs) and Licensed Nurses

1. Non-Physician Practitioners: All non-physicians defined as eligible providers under a member’s BCBSKS contract, who are providing services within their Kansas licensure or certification scope, must bill their charges to BCBSKS under their own National Provider Identifier (NPI) or specific performing provider number, if applicable. The name of the ordering provider (including NPI, except when exempt by law) must appear on every claim.
2. Licensed Nurses (Other Than APRNs): A physician may bill for the services of a licensed nurse (who is not an Advanced Practice Registered Nurse) under the following conditions:
   • An employer/employee relationship exists between the physician and the nurse.
   • The services are directly supervised by the physician.
   • Definition of Supervision: For these purposes, supervision means:
     • The patient recognizes the supervising physician as their primary physician.
     • There is a periodic review of the patient’s records by the physician. This includes, for example, the physician routinely reviewing and co-signing notes, treatment plans, and progress reports generated by the nurse, ensuring quality of care and adherence to medical standards.
     • The services must be an integral part of the physician’s professional service. This means the nurse’s services are directly related to the physician’s overall management of the patient’s care and contribute to the treatment plan established by the physician, commonly furnished in the physician’s office or clinic. For instance, a nurse performing wound care follow-ups or administering injections under the physician’s standing orders.
   • These services must be included in the physician’s bill.
3. Advanced Practice Registered Nurses (APRNs): Independently practicing APRNs who provide services as defined in their Kansas licensure or certification must bill their charges to BCBSKS under their own NPI or specific performing provider number. The name of the ordering provider (including NPI, except when exempt by law) must appear on every claim. These APRN billing guidelines Kansas specific ensure proper identification and processing of claims.

BCBSKS Resident Physician Billing: In-Program vs. Outside-of-Program Services

The method for BCBSKS resident physician billing depends significantly on whether the services are provided as part of their residency program or independently. Understanding this distinction is key for correct NPI usage and claim submission:

1. Services in Connection with the Residency Program: If a Resident Physician provides services as an integral part of their Residency Program, these services are billed under the attending Faculty Physician’s NPI or specific performing provider number. This reflects the supervisory nature of residency training where the faculty physician bears ultimate responsibility.
2. Services Outside of the Residency Program: If the Resident Physician is providing services independently, outside the scope of their official Residency Program, then all standard Blue Shield Policy Memos apply. In such cases, the services must be billed under the Resident Physician’s own NPI or specific performing provider number. This typically applies when a resident is moonlighting or providing services in a capacity separate from their training.

General Billing Requirements for All Providers

6. Licensure and Eligibility: BCBSKS will not pay for any services performed and billed by an independent provider who does not meet applicable state or national licensure, registration, or certification requirements for that service, or who is not defined as an eligible provider in the member’s contract.
7. Outpatient Nervous and Mental Health Services: BCBSKS will not pay for outpatient services connected with a nervous and mental diagnosis when provided by an unlicensed provider, or a licensed provider whose licensure is not designated in the member’s contract as eligible to provide nervous and mental benefits. Supervision of an unlicensed provider, a licensed counselor, or one not designated as eligible in the member’s contract does not constitute a service being rendered by an eligible provider. The exceptions include services rendered through a state-licensed alcohol or drug abuse treatment facility, a hospital, psychiatric hospital, or a community mental health center. Eligible non-physician psychiatric providers include APRNs, certified psychologists, licensed specialist clinical social workers, licensed clinical marriage and family therapists, licensed clinical professional counselors, and licensed clinical psychotherapists.

BCBSKS Locum Tenens Provider Billing: Rules, NPI, and Q6 Modifier

When a regular provider is unavailable, a locum tenens provider can step in to ensure continuity of patient care. Here are the BCBSKS locum tenens provider billing guidelines, including rules for locum tenens NPI usage and the Q6 modifier locum tenens requirement:

• Provider Type Match: The locum tenens must be the same type of provider as the one they are substituting for (e.g., a physician can only authorize another physician; an APRN/PA can only authorize another APRN/PA).
• Kansas Licensure and Scope of Practice: The locum tenens must be licensed in Kansas and only perform services within their specific scope of license.
• 60-Day Rule and Extensions: A locum tenens must not provide services for a continuous period longer than 60 days.
  • Before the 60-Day Limit: If an extension is needed beyond the 60 days, providers must contact BCBSKS well in advance of the deadline to discuss potential billing arrangements. This proactive communication is crucial to avoid claim rejections.
  • Billing Arrangements: These discussions might involve applying for a temporary provider number for the locum tenens, specific contractual agreements, or other administrative solutions to allow continued billing under BCBSKS guidelines.
• Claim Submission for Locum Tenens Services:
  • Claims must be filed using the NPI or specific performing provider number of the provider for whom the locum tenens is substituting. This is a critical point for locum tenens NPI usage.
  • A Q6 modifier locum tenens must be used on the claim to indicate that the services were provided by a substitute physician.
  • The medical record must clearly indicate that the services were provided by a locum tenens provider.