Nurse Practitioner and Physician Assistant Credentialing With Insurance Payers

Medicare does not set its own collaboration rule. Its Benefit Policy Manual says NP services must be performed in collaboration with a physician “as required by the law of the State,” and that the collaborating physician does not need to be present or to see each patient. For PAs, it says any state rule describing the physician relationship, supervisory or collaborative, is the supervision Medicare requires. Commercial payers ask for the same proof.

In Florida, that proof depends on which path the clinician is on:

• APRN under a protocol (Fla. Stat. 464.012). The APRN practices within an established protocol with a supervising physician, kept on site at each practice location. Florida requires national certification for initial APRN licensure and every renewal.
• Autonomous APRN (Fla. Stat. 464.0123). The Board of Nursing registers an APRN for autonomous practice after at least 3,000 clinical hours under physician supervision in the prior five years, graduate coursework in differential diagnosis and pharmacology, and no discipline in five years. The registration is limited to primary care, including family medicine, general pediatrics and general internal medicine, and requires at least $100,000 per claim and $300,000 aggregate in coverage or a letter of credit.
• Physician assistant (Fla. Stat. 458.347). A PA practices under a supervising physician, who may supervise no more than 10 PAs at a time. Licensure requires passing the NCCPA examination, and the supervising physician must notify the Department of Health before delegating prescribing authority.

Other states differ: some allow full practice for NPs, some require a written collaborative agreement filed with the board. Check your state board's current rule before you apply, because the payer will.

Since January 1, 2022, Medicare can pay a PA directly. The Benefit Policy Manual (ch.15 §190) says “direct billing and payment for PA services may be made to the PA,” and the Claims Processing Manual (ch.12 §110.4) requires PAs to have their own NPI for billing, under Medicare specialty code 97. Before that date only the PA's employer could be paid. In practice most PAs still reassign to their group, but a PA can now enroll and bill in their own name, or with other PAs, where state law allows it.

Medicare covers PA services performed under the general supervision of a physician, as state law defines it. Commercial plans write their own PA rules, so check each payer's manual rather than assuming the Medicare change carried over.

• Florida Blue groups APRNs, PAs and similar clinicians as Advanced Non-Physician Practitioners. Every one must obtain a Florida Blue provider number and register their NPI. Individually contracted ones, and any who are the only participating practitioner under a tax ID, must go through credentialing. For the rest, the physician group is responsible for licensure, supervision and registration (Provider Manual §01).
• Humana lists nurse practitioners and physician assistants among the practitioners it credentials, and says a provider appears in its directory only once credentialing is complete (credentialing policy).
• Aetna credentials the practitioners it contracts with individually and names nurse practitioners among them (medical credentialing).

The practical rule: ask each payer, in writing, whether the NP or PA needs their own application and contract, or only registration under the group. Payer-specific steps are in our guides to Blue Cross Blue Shield, Humana and Aetna, and the full list is on the payer credentialing hub.

1. Confirm your practice path in your state: protocol, collaborative agreement, autonomous registration or PA supervision, and have it signed.
2. Fix the NPI record: correct taxonomy, current practice address.
3. Build or clean up CAQH, upload current documents, authorize the plans, and attest. See CAQH explained.
4. File Medicare on the CMS-855I with reassignment to the group in Section 4F.
5. File Medicaid with your state program.
6. Apply to each commercial payer in parallel, after confirming the supervising physician is already in that network.
7. Follow up weekly, answer every request the same week, and get the effective date in writing before scheduling that payer's patients.

The longer version, for any provider type, is how to get in network with insurance companies.

The letters after your name are your board certification, and they are one of the things payers verify. ANCC awards the FNP-BC for five years (ANCC); AANPCB grants its NP certifications for five-year periods (AANPCB); NCCPA's PA-C runs on a 10-year maintenance process with 100 CME credits every two years (NCCPA). A lapse in any of them shows up at the next payer recredentialing, so the renewal date belongs on the same calendar as CAQH re-attestation.

• CMS, Medicare Benefit Policy Manual, ch.15 — §60.1 incident to, §190 PA services and direct payment, §200 NP qualifications, certifying bodies and collaboration.
• CMS, Medicare Claims Processing Manual, ch.12 — §110, §110.4 and §120, PA and NP payment and PA NPI requirement.
• CMS, Consolidated CMS-855I/CMS-855R bulletin — 855R discontinued, reassignment on the 855I.
• CMS, Program Integrity Manual, ch.10 — §10.5 MAC processing standards.
• First Coast, New provider roadmap — Florida Medicare enrollment steps.
• Florida Statutes 464.012, 464.0123 and 458.347 — APRN protocol, autonomous practice, PA supervision.
• NUCC, Health Care Provider Taxonomy code set v26.1.
• Florida Blue, Provider Manual §01 — Advanced Non-Physician Practitioners, decision timing.
• Humana, Credentialing and Recredentialing Policy.
• Aetna, Medical credentialing.
• ANCC FNP, AANPCB certifications and NCCPA certification maintenance.