Nonphysician Provider (NP, PA) Scopes of Practice

Palmetto GBA recognizes that each state may have variations in their scopes of practice as well as variations in which services within their scope of practice are being provided in different geographic regions. In the event that an NPP receives a denial for a service they believe falls within their state's scope of practice, a request may be submitted for Palmetto GBA to consider opening that code for NPP coverage.

These requests must be directed to the Medical Affairs department at B.Policy@PalmettoGBA.com and must include a claim example of a denied service for that CPT/HCPC code along with a copy of the NPP's state scope of practice. If the scope of practice does not specifically authorize the procedure then additional documentation will be required to include a copy of the NPP’s supervisory agreement, and documentation that training for the procedure was included in the course of study for the NPP program attended, or evidence of appropriate training for the specific procedure. If it is determined that the service is within the NPP’s state scope of practice, Palmetto GBA will open that code for coverage when performed by NPPs.

Note: Only requests to open coverage for a CPT/HCPC code that has been denied because of the provider’s specialty can be addressed through this manner. A request to open coverage for a specific NPP service is not an appeal request for an individual claim. The appeal process must be used for any other type of denial/rejection for NPP services.