“Incident to” Billing Policy

PacificSource credentialing standards follow the guidelines of the National Committee on Quality Assurance (NCQA). The PacificSource and delegate credentialing process includes meticulous verification of the education, experience, judgment, competence, and licensure of all healthcare providers.

PacificSource allows “incident to” billing for caregivers who are not eligible to be credentialed by PacificSource or a delegated credentialing entity. This provides practices the opportunity to fully utilize their staff appropriately. PacificSource does NOT allow “incident to” billing for practitioners who are eligible for credentialing.

Effective June 1, 2018, in order for a service to be considered for payment under the “incident to” billing policy, the modifier SA must be appended to the CPT code. Only claims with the required SA modifier, will be considered eligible for “incident to” billing.

In limited situations, PacificSource allows for exceptions to the credentialing and modifier SA requirements. Examples of these exceptions are:

  • In the event that another policy exists that conflicts with this policy and allows exception to this rule, precedence will be given first to the rules of that policy. For example, PacificSource does allow for licensed behavioral health professionals who are eligible for credentialing to bill under the “incident to” status if the services being rendered are part of an applied behavior analysis (ABA). These services are exempt from the modifier SA requirement.
  • The CPT/HCPCS code being billed is inherently considered a collaborative care service, such as G0511 and G0512 for Care Coordination Services or G0502, G0503, G0504, and G0507 for Behavioral Health Integration Services. These codes are exempt from the modifier SA requirement. PacificSource will follow CMS Guidelines in the use and payment of these types of services.

In order to provide care that will be billed to PacificSource using “incident to” status, the caregiver must be ineligible to be credentialed by PacificSource or its delegated credentialing entity. In addition, if the caregiver’s profession is licensable in the state where services are provided (e.g., nursing, social work), then the caregiver must hold an active license and be providing services within the scope of that license. If the caregiver’s profession is not licensable in the state where services are provided (e.g., medical assistants, community health workers), then the caregiver must be working under the license and within the scope of practice of the licensed clinician under whom services are being billed. PacificSource requires strict adherence to the following guidelines, and these criteria must be met in order for services to be billed as “incident to.”

PacificSource allows “incident to” billing only if the following criteria met:

  1. The patient must be established in the practice.
  2. The services must be provided under the direct supervision of the physician or credentialed, qualified non-physician practitioner.
  3. The supervising provider must actively participate in the continuation of the patient’s course of care, with periodic face-to-face encounters. Care may not be transferred to a non-credentialed provider.
  4. The original supervising provider, or similarly qualified substitute supervising provider, must be present in the office suite at the time of service delivery and available to provide any necessary assistance.
  5. The patient must have a covered condition that was initially diagnosed by the supervising provider.
  6. The services must be medically necessary and an integral part of the patient’s care.
  7. Services must be rendered in a physician’s office or clinic (not in an institutional setting).
  8. Services rendered under the “incident to” billing policy must be billed under the credentialed, supervising provider.
  9. PacificSource will adhere to CPT Billing Guidelines in the payment of services billed under the “incident to” billing policy.
  10. The caregiver billing under the supervising provider must be an employee of the practice (i.e., a W-2 employee).

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Last updated 4/27/2018