Incident to Supervision Requirements

This article summarizes supervision requirements for incident-to billing across major payers relevant to our practice, with a focus on behavioral health services. It also integrates Oklahoma state law regarding Nurse Practitioners (NPs) and Physician Assistants (PAs).

Definitions

Direct Supervision

• Means the supervising physician or other qualified practitioner is physically present in the office suite (or location of service) and immediately available to provide assistance and direction during the entire time the service is being performed.

• They do not have to be in the same room, but must be close enough to step in “without delay.”

• Payers like UHC, BCBS, and CommunityCare commercial lines explicitly require this standard.

General Supervision

• Means the service is performed under the overall direction and control of the supervising physician or practitioner.

• The supervisor’s physical presence is not required during the service.

• The supervisor is responsible for training, protocols, and ongoing involvement in the patient’s care, but can be available remotely (e.g., phone, telecommunication).

• CMS allows this lower threshold for certain services, including the behavioral health exception.

1. CMS / Medicare

• Supervision rule: General supervision allowed for behavioral health services (42 CFR §410.26; MLN1986542).
• Definition: General supervision = overall direction and control; physical presence not required.
• Risk: ✅ Low risk / OK. Medicare explicitly allows general supervision for BH incident-to.

2. UnitedHealthcare (UHC) Commercial

• Supervision rule: Requires direct personal supervision (supervisor on-site and immediately available). No BH carve-out.
• Risk: High risk. State law allows remote oversight, but UHC commercial policy does not.

3. Optum Behavioral Health

a. Optum Medicare

• Supervision rule: General supervision allowed (policy revised in 2023 to align with CMS).
• Risk: ✅ Low risk / OK.

b. Optum Commercial

• Supervision rule: Defers to state law but does not adopt CMS BH exception. Treated as direct supervision unless contract states otherwise.
• Risk: Moderate risk. State law allows remote oversight, but payer audits may still expect on-site.

4. Blue Cross Blue Shield (BCBS)

• Plans: Oklahoma, Texas, Illinois (HCSC plans).
• Supervision rule: Direct personal supervision required = immediate vicinity / on-site, 100% of the time.
• Risk: High risk. No general supervision carve-out for BH.

5. HealthChoice (Oklahoma EGID)

• Supervision rule: No explicit incident-to policy. Typically defers to CMS guidance unless contract states otherwise.
• Risk: ✅ Low risk / OK if CMS rules are applied. Confirm via contract.

6. CommunityCare of Oklahoma (CCOK)

a. Commercial (HMO / PPO)

• Supervision rule: Defaults to direct/personal supervision. No BH exception in HMO provider manual.
• Risk: High risk.

b. Medicare Advantage

• Supervision rule: Follows CMS → general supervision OK.
• Risk: ✅ Low risk / OK.

7. Oklahoma State Law Context

• Physician Assistants (59 O.S. §519.6): Supervising physician need not be physically present; telecom supervision acceptable if oversight, protocols, and chart review maintained.
• Nurse Practitioners (59 O.S. §567.4a): Must have a supervision agreement for prescribing; on-site presence not required. From Nov 2025, certain APRNs will gain independent prescriptive authority after 6,240 supervised hours.

8. Practical Guidance

• Medicare (CMS, Optum MA, CCOK MA): General supervision allowed → safe to bill incident-to.
• Commercial (UHC, Optum Commercial, BCBS, CCOK Commercial): Require on-site direct supervision → billing incident-to with general supervision is high risk.
• HealthChoice: Likely aligns with CMS, but confirm contractually.

9. Quick Reference Table

Bottom line: In Oklahoma, state law for PAs and NPs is more permissive, but commercial payers (UHC, Optum Commercial, BCBS, CCOK Commercial) impose stricter direct/on-site supervision rules. For Medicare lines of business, general supervision is acceptable and low risk.