Certified Nurse Practitioner Services

(A) General. 130 CMR 433.433 applies specifically to certified nurse practitioners (also known as nurse practitioners). In general, however, subject to compliance with state and federal law, the requirements and limitations elsewhere in 130 CMR 433.000 that apply to physicians also apply to certified nurse practitioners, such as service and payment limitations, recordkeeping and reporting requirements, and prior-authorization and other conditions of coverage. (B) Conditions of Payment. The MassHealth agency pays either an independent certified nurse practitioner or group practice (in accordance with 130 CMR 433.433(C)), or the physician employer of a nonindependent certified nurse practitioner (in accordance with 130 CMR 433.433(E)), for certified nurse practitioner services when: (1) the services are limited to the scope of practice authorized by state law or regulation (including but not limited to 244 CMR: Board of Registration in Nursing or of the state licensing agency of another state in which the services are provided); 4 Program Regulations (2) the certified nurse practitioner or group practice is not an employee of the hospital or other facility in which the certified nurse practitioner services were performed, or is not otherwise paid by the hospital or facility for the service; (3) (a) in the case of payment claimed by an independent certified nurse practitioner, or a group practice, the certified nurse practitioner participates in MassHealth pursuant to the requirements of 130 CMR 433.433(C); or (b) in the case of payment claimed by a physician employer of a nonindependent certified nurse practitioner, the conditions of 130 CMR 433.433(E) are met; and (4) for an out of state certified nurse practitioner the requirements of 130 CMR 433.403(C) are met. (C) Independent Certified Nurse Practitioner Provider Eligibility: Submission Requirements. Only a certified nurse practitioner who meets the following requirements may enroll in MassHealth as an independent certified nurse practitioner: (1) is licensed to practice as a certified nurse practitioner by the Massachusetts Board of Registration in Nursing or by the licensing agency of another state in which the certified nurse practitioner services are provided; and (2) is a member of a group practice or is in a solo private practice. (3) Any certified nurse practitioner applying to participate as an independent provider in MassHealth must submit documentation satisfactory to the MassHealth agency that he or she meets these requirements. (D) Consultation Between Certified Nurse Practitioner and Physician. The MassHealth agency does not pay for a consultation between a certified nurse practitioner and a physician as a separate service. (E) Submitting Claims for Nonindependent Certified Nurse Practitioners. Any certified nurse practitioner who does not meet the requirements of 130 CMR 433.433(C)(2) is a nonindependent certified nurse practitioner and is not eligible to submit claims to MassHealth. As an exception to 130 CMR 450.301: Claims, an individual physician (who is neither practicing as a professional corporation nor a member of a group practice) who employs a nonindependent certified nurse practitioner may submit claims for services provided by a nonindependent certified nurse practitioner employee, but only if: (1) the nonindependent certified nurse practitioner is licensed to practice as a certified nurse practitioner by the Massachusetts Board of Registration in Nursing or by the licensing agency of another state in which the certified nurse practitioner services are performed; (2) such services are provided in accordance with 130 CMR 433.433(B); and (3) payment is claimed by the physician employer in accordance with 130 CMR 450.301(B): Claims. (Refer to Subchapter 6 of the Physician Manual for appropriate modifiers.)