Nonphysician Practitioners - Additional Enrollment Requirements

November 28, 2007

Documentation requirements for non-physician practitioners

The Centers for Medicare and Medicaid Services (CMS) has established criteria for determining the eligibility of non-physician practitioners for enrollment and reimbursement under Part B of the Medicare program. Specific guidelines for non-physician practitioner professions are outlined below. Medicare requires that this information be submitted with the form CMS 855I enrollment application before a provider transaction number may be issued to you.

If you are submitting a CMS 855I application, attach the appropriate degree, certificate, or documentation demonstrating that you have met the requirements for your provider type.

Anesthesiologist assistant

A qualified anesthesiologist assistant must:

• Be licensed by the state to administer anesthesia and

• Have successfully completed a six year program for anesthesia assistants, of which two years consists of specialized academic and clinical training in anesthesia.

Audiologist

A qualified audiologist is an individual who must:

• Be licensed by the state as an audiologist.

Certified nurse midwife (CNM)

A certified nurse midwife must:

• Be licensed as a nurse midwife.

Certified registered nurse anesthetist (CRNA)

A CRNA must:

• Be currently licensed in Florida as a registered nurse and

• Be currently certified by the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists; or

• Have graduated within the past 18 months from a nurse anesthesia program that meets the standards of the Council of Accreditation of Nurse Anesthesia Educational Programs and is awaiting initial certification.

Note: A copy of the Council on Certification of Nurse Anesthetists, or the Council on Recertification of Nurse Anesthetists card may be submitted as documentation in addition to the state license.

Clinical nurse specialist (CNS)

Coverage is available for services performed by a CNS and direct payment can be made to the CNS, or the employer or contractor of the CNS who:

• Is licensed by the state as a registered nurse and

• Possesses a master’s degree in a defined clinical area of nursing from an accredited educational institution; and

• View the accredited educational institutes at http://www.nursecredentialing.org/accred/searchaccred.cfm

. Ensure the master’s degree is from one of these organizations.

• Be certified as a clinical nurse specialist by a recognized national certifying body that has established standards for CNSs.

The following are recognized national certifying bodies for CNSs at the advanced level:

• American Academy of Nurse Practitioners

• American Nurses Credentialing Center

• National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties

• Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses)

• Oncology Nurses Certification Corporation

• AACN Certification Corporation

• National Board on Certification of Hospice and Palliative Nurses

Registered dietitian or nutrition professional

A registered dietitian or nutrition professional is an individual who:

• Is a dietitian or nutrition professional licensed in Florida.

Licensed clinical social worker (LCSW)

An LCSW is an individual who:

• Is licensed as a clinical social worker in Florida.

Physical therapist (PT) in private practice

A Qualified physical therapist is an individual who:

• Is licensed by the state as a physical therapist and meets one of the following requirements:

• Has graduated from a physical therapy curriculum approved by (1)*the American Physical Therapy Association, or by (2) the Committee on Allied Health Education and Accreditation of the American Medical Association, or (3) Council on Medical Education of the American Medical Association, and the American Physical Therapy Association; or

• Prior to January 1, 1966, (1) was admitted to membership by the American Physical Therapy Association, or (2) was admitted to registration by the American Registry of Physical Therapists, or (3) has graduated from a physical therapy curriculum in a 4-year college or university approved by a state department of education; or

• Has 2 years of appropriate experience as a physical therapist and has achieved a satisfactory grade on a proficiency examination conducted, approved, or sponsored by the Public Health Service, except that such determinations of proficiency do not apply with respect to persons initially licensed by a state or seeking qualification as a physical therapist after December 31, 1977; or

• Was licensed or registered prior to January 1, 1966, and prior to January 1, 1970, had 15 years of full-time experience in the treatment of illness or injury through the practice of physical therapy in which services were rendered under the order and direction of attending and referring doctors of medicine or osteopathy; or

• If trained outside the United States, (1) was graduated since 1928 from a physical therapy curriculum approved in the country in which the curriculum was located and in which there is a member organization of the World Confederation for Physical Therapy, (2) meets the requirements for membership in a member organization of the World Confederation for Physical Therapy.

Occupational therapist (OT) in private practice

Note: A therapist in private practice must maintain a private office even if services are always furnished in patients’ homes. If services are furnished in private practice office space, that space would have to be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice. If the applicant is an organization, the organization must be wholly owned by one or more occupational therapist(s) that is practicing at the location.

An occupational therapist must:

• Be licensed as an occupational therapist in Florida.

Nurse practitioner (NP)

Note: Effective for services rendered after January 1, 1998, any individual who is participating under the Medicare program as a nurse practitioner (NP) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below, and he or she is legally authorized to furnish NP services in the State where the services are performed. NPs who were issued billing provider numbers prior to January 1, 1998 may continue to furnish services under the NP benefit.

Qualifications for NPs. In order to furnish covered NP services, a NP must meet the conditions as follows:

A nurse practitioner who applied for Medicare billing privileges for the first time on or after 01/01/01 must:

• Be a registered professional nurse who is authorized by the state in which services are furnished to practice as an NP in accordance with state law, and

• Must be certified as a NP by a recognized national certifying body* having established standards for NPs.

A nurse practitioner who applied for Medicare billing privileges for the first time on or after 01/01/03 must:

• Be a registered professional nurse who is authorized by the state in which services are furnished to practice as an NP in accordance with state law, and

• Must be certified as a NP by a recognized national certifying body* having established standards for NPs and

• Possess a master’s degree in nursing.

*The following organizations are recognized national certifying bodies:

• American Academy of Nurse Practitioners;

• American Nurses Credentialing Center;

• National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;

• National Certification Board of Pediatric Nurse Practitioners & Nurses;

• Oncology Nurses Certification Corporation; and

• Critical Care Certification Corporation.

Physician assistant (PA)

A physician assistant must:

• Be licensed by the state as a physician assistant – temporary licenses are not acceptable.

Clinical psychologist

A clinical psychologist must:

• Be licensed by the state as a psychologist.

Source: CMS Program Integrity Manual Ch. 10 Sec. 12.4;
Code of Federal Regulations, Title 42