Provider Qualifications

Table of Contents

• Physicians - Psychiatrists
• Clinical Psychologist
• Independently Practicing Psychologist (IPP)
• Clinical Social Worker
• Marriage and Family Therapist (MFT)
• Mental Health Counselor (MHC)
• Physician Assistant (PA)
• Nurse Practitioner (NP)
• Clinical Nurse Specialist (CNS)
• Certified Nurse-Midwife (CNM)

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Physicians - Psychiatrists

A physician is defined as a doctor of medicine or osteopathy who is legally authorized to practice medicine in the state in which he/she performs services. The issuance by a state of a license to practice constitutes legal authorization. If state licensing law limits the scope of practice of a particular type of medical practitioner, only the services within those limitations are covered.
Note: The term physician does not include Christian Science practitioners

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Clinical Psychologist

To qualify as a CP, the following requirements must be met:

• Hold a doctoral degree in psychology;
• Be licensed or certified, on the basis of the doctoral degree in psychology, by the state in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.

Covered Services

CPs may provide the following services:

• Diagnostic and therapeutic services that a CP is legally authorized to perform in accordance with state law and/or regulation.
• Services and supplies furnished incident to a CP’s services are covered if the requirements that apply to services incident to a physician’s services are met.
  • These services must be mental health services that are commonly furnished in CP’s offices.
  • An integral, although incidental, part of professional services performed by the CP.
  • They must be performed under the direct personal supervision of the CP (the CP must be physically present and immediately available) and
  • Furnished without charge or included in the CP bill.
  • Any person involved in performing the service must be an employee of the CP (or an employee of the legal entity that employs the supervising CP).

Noncovered Services

The services of CPs are not covered if the service is otherwise excluded from Medicare coverage even though a clinical psychologist is authorized by state law to perform them. Therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not covered.

Requirement for Consultation

When applying for a Medicare provider number, a CP must submit to the contractor a signed Medicare provider/ supplier enrollment form that indicates an agreement to the effect that, contingent upon the patient’s consent, he or she will attempt to consult with the patient’s attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality.

If the patient assents to the consultation, the CP must attempt to consult with the patient’s physician within a reasonable time after receiving the consent. If the CP’s attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient’s medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.

The only exception to the consultation requirement for CPs is in the cases where the patient’s primary care or attending physician refers the patient to the CP. Neither a CP nor a primary care nor attending physician may bill Medicare or the patient for this required consultation.

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Independently Practicing Psychologist (IPP)

To qualify as an Independent Psychologist/Nonclinical Psychologist (NCP), a practitioner must meet the following requirements:

• Is a psychologist who is not a CP; and meets one of the following criteria:
  • Practices independently of an institution, agency, or physician’s office and is licensed or certified to practice psychology in the state or jurisdiction where the services are performed; or
  • Is a practicing psychologist who performs services in a jurisdiction that does not issue licenses.

Coverage of Services

The following coverage criteria apply:

• Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary;
• Performs services on his or her own responsibility, free of the administrative and professional control of an employer (for example, a physician, an institution, or an agency);
• The individuals treated are his or her own patients;
• When he or she practices in an office that is located in an institution, the office is confined to a separately-identified part of the facility that he or she uses solely as an office and cannot be construed as extending throughout the entire institution; and
• He or she conducts a private practice (services are furnished to patients outside the institution as well as to institutional patients);
• He or she may perform diagnostic psychological and neuropsychological tests when a physician orders such tests; and
• He or she has the right to bill directly and collect and retain the fee for his or her services.

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Clinical Social Worker

He or she must meet the following qualifications:

• Has a Master's or Doctoral degree in social work;
• Has performed at least two years of supervised clinical social work; and
• Is licensed or certified as a CSW by the state in which the services are performed; or
• If the individual practices in a state that does not provide for licensure or certification, has completed at least two years or 3,000 hours of post Master’s degree supervised clinical social work practice under the supervision of a Master’s level social worker in an appropriate setting (for example, a hospital, SNF or clinic).

Coverage of Services

The following coverage criteria apply:

• He or she is legally authorized to furnish the services in the state where they are performed;
• Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary;
• Services are for the diagnosis and treatment of mental illnesses;
• CSW services furnished to hospital inpatients are not covered as CSW services;
• CSW services to hospital outpatients are covered and paid under the CSW benefit when billed by the hospital to a MAC under the CSW's NPI;
• CSW services furnished to patients under a Partial Hospitalization Program that is provided by a hospital outpatient department or Community Mental Health Center are not covered and paid under the CSW benefit;
• CSW services furnished to SNF inpatients and patients in Medicare-participating ESRD facilities are not covered and paid under the CSW benefit if the services furnished are required under the respective requirements for participation;
• Incident to services that CSWs furnish for physicians, CPs, CNSs, NPs, PAs, or CNMs may be covered; and
• Services furnished as an incident to a CSW’s personal professional services are not covered.

Noncovered Services

Services of a CSW are not covered by Medicare Part B when furnished to inpatients of a hospital, patients of a partial hospitalization program, or to inpatients of a SNF if the services furnished in the SNF are those that the SNF is required to furnish as a condition of participation with Medicare. In addition, CSW services are not covered if they are otherwise excluded from Medicare coverage even though a CSW is authorized by state law to perform them. Therapeutic services that are billed by a CSW under CPT psychotherapy codes that include E/M services are not covered. CSWs may not bill for pharmacological management. Also, there is no provision for billing services rendered incident to a CSW.

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Marriage and Family Therapist

A marriage and family therapist is defined as an individual who:

• possesses a master's or doctor's degree which qualifies for licensure or certification as a marriage and family therapist pursuant to state law of the state in which such individual furnishes the services defined as marriage and family therapist services;
• after obtaining such degree, has performed at least two years or 3,000 hours of post master's degree clinical supervised experience in marriage and family therapy in an appropriate setting such as a hospital, SNF, private practice, or clinic; and
• is licensed or certified as a marriage and family therapist by the state in which the services are performed.

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Mental Health Counselor (MHC)

A mental health counselor is defined as an individual who:

• possesses a master's or doctor's degree which qualifies for licensure or certification as a mental health counselor, clinical professional counselor, professional counselor under the State law of the State in which such individual furnishes the services defined as mental health counselor services;
• after obtaining such a degree, has performed at least two years or 3,000 hours of post master's degree clinical supervised experience in mental health counseling in an appropriate setting such as a hospital, SNF, private practice, or clinic; and
• is licensed or certified as a mental health counselor, clinical professional counselor, professional counselor by the state in which the services are performed.

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Physician Assistant (PA)

You must meet the following qualifications:

• Licensed by the state where you practice and one of the following criteria:
  • Graduated from PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs and the Committee on Allied Health Education and Accreditation
  • Passed the national certification examination administered by the National Commission on Certification of Physician Assistants

The following coverage criteria applies:

• Legally authorized to practice medicine in the state where you furnish services
• Medicare does not statutorily preclude the services, and they are reasonable and necessary
• Medicare considers the services physicians’ services if furnished by an MD or DO
• Services are furnished by an individual who meets all PA qualifications
• The physician supervisor or designee need not be physically present when a service is furnished unless state law or regulations require otherwise
• Medicare may cover assistant-at-surgery services you furnish
• May personally furnish diagnostic psychological and neuropsychological tests with a physician as required under the PA benefit and as permitted under state law
• Medicare may cover “incident to” services and supplies

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Nurse Practitioner (NP)

You must meet the following qualifications:

• Registered nurse currently licensed in the state you practice and authorizes you to furnish CNS services according to state law
  • Obtained Medicare NP billing privileges for the first time since 1/1/2003 and; are NP certified by a recognized national certifying body with established NP standards
  • Master's degree in nursing or a Doctor of Nursing Practice Doctoral degree

The following coverage criteria applies:

• Legally authorized to practice medicine in the state where you furnish services
• Medicare does not statutorily preclude the services, and they are reasonable and necessary
• You furnish the services with a physician
• Medicare may cover assistant-at-surgery services you furnish
• May personally furnish diagnostic psychological and neuropsychological tests with a physician as required under the NP benefit and as permitted under State law
• Medicare may cover “incident to” services and supplies

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Clinical Nurse Specialist (CNS)

You must meet the following qualifications:

• Registered nurse currently licensed to practice in the state where you practice and authorizes you to furnish CNS in accordance with state law
• Doctor of Nursing Practice or Master's degree in a defined clinical nursing area of nursing from an accredited educational institution
• Certified as a CNS by a recognized national certifying body with established CNS standards

The following coverage criteria applies:

• Legally authorized to practice medicine in the state where you furnish services
• Medicare does not statutorily preclude the services, and they are reasonable and necessary
• Medicare considers the services physicians’ services if furnished by an MD or DO
• You furnish the services with a physician
• Medicare may cover assistant-at-surgery services you furnish
• May personally furnish diagnostic psychological and neuropsychological tests with a physician as required under the CNS benefit and as permitted under state law
• Medicare may cover “incident to” services and supplies

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Certified Nurse-Midwife (CNM)

You must meet the following qualifications:

• RN legally authorized to practice as a nurse-midwife in the state where you furnish services
• Successfully completed a nurse-midwives program of study and clinical experience accredited by an accrediting body approved by the U.S. Department of Education
• Certified as a nurse-midwife by the American College of Nurse-Midwives or the American College of Nurse-Midwives Certification Council

The following coverage criteria applies:

• Legally authorized to practice medicine in the state where you furnish services
• Medicare does not statutorily preclude the services and they are reasonable and necessary
• Medicare considers the services physicians’ services if furnished by an MD or DO
• Furnish services without physician supervision and without association with a physician or other health care provider, unless otherwise required under state law
• May personally furnish diagnostic psychological and neuropsychological tests without physician supervision or oversight as authorized by the CNM benefit and permitted under state law
• Medicare may cover “incident to” services and supplies

Noncovered Services

The services of CPs are not covered if the service is otherwise excluded from Medicare coverage even though a clinical psychologist is authorized by state law to perform them. Therapeutic services that are billed by CPs under CPT psychotherapy codes that include medical evaluation and management services are not covered.

In addition Medicare FFS does not cover the following mental health services:

• Environmental intervention or modifications
• Adult day health programs
• Biofeedback training (any modality)
• Marriage counseling
• Pastoral counseling
• Report preparation
• Results or data interpretation or explanation
• Schizophrenia hemodialysis treatment
• Transportation or meals
• Phone services, or “apps”

Requirement for Consultation

When applying for a Medicare provider number, a CP must submit to the contractor a signed Medicare provider/supplier enrollment form that indicates an agreement to the effect that, contingent upon the patient’s consent, he or she will attempt to consult with the patient’s attending or primary care physician in accordance with accepted professional ethical norms, taking into consideration patient confidentiality.

If the patient assents to the consultation, the CP must attempt to consult with the patient’s physician within a reasonable time after receiving the consent. If the CP’s attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. Additionally, the CP must document, in the patient’s medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.