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Locum Tenens Process Change to Take Effect June 1, 2018

Effective June 1, 2018, Highmark will no longer accept locum tenens forms.

This change is being implemented to ensure Highmark’s compliance with Centers for Medicare & Medicaid Services (CMS) billing requirements (Medicare Claims Processing Manual, Chapter 1, Section 30.2.11). Those requirements outline the specific payment conditions that must be met when a physician retains a locum tenens (substitute physician).

Compliance Requirements

Physicians may retain substitute physicians to take over their professional practices when they are absent for reasons such as:

  • illness
  • pregnancy/maternity leave
  • vacation
  • continuing medical education

Billing Requirements

A physician may bill and receive payment for a substitute physician’s “covered visit services” as though he/she performed them. In such situations, “covered visit services” include not only those services ordinarily characterized as a covered physician visit, but also any other covered items and services furnished by the substitute physician or by others as “incident to” the physician’s services.

A physician may submit a claim and (if assignment is accepted) receive payment for covered visit services of a substitute physician if:

  • The regular physician is unavailable to provide the services.
  • The member has arranged or seeks to receive the services from the regular physician.
  • The regular physician pays the substitute for his/her services on a per diem or similar fee-for-time basis.
  • The substitute physician does not provide the services to patients over a continuous period of longer than 60 days subject to the following exception:
    • A physician called to active duty in the Armed Forces may bill for services furnished under a fee-for-time compensation arrangement for longer than the 60-day limit.

In these cases, the physician indicates that the services were provided by a substitute physician under a fee-for-time compensation arrangement meeting the requirements of this section by entering HCPCS code modifier Q6 after the procedure code. (Modifier Q6 — Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area).

If the only services a physician performs in connection with an operation are post-operative services furnished during the period covered by the global fee, these services need not be identified on the claim as services furnished by a substitute physician.

Please note: Claims submitted with a Q6 modifier will be subject to ongoing monitoring and audit for fraudulent billing activity.
Please review the Highmark Blue Shield Office Manual or Highmark Facility Manual for more information on how to fully credential your providers.