Reduction Reason
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Description
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Certified Diabetic Educator
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Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- 97802-97804, 98960 – 98962, G0108, G0109, and S9145
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Certified Registered Nurse Anesthetist
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Allowed at 85% of PPS for non-anesthesia services |
Chiropractor
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Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, DME and Prosthetics, Physical and Occupational Therapies/Modalities, Radiology services, and Diagnostic tests.
- 74263, 76706, 77063, 77067
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Clinical Nurse Specialist
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Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- 74263, 76706, 77063, 77067, 99002, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190, S0191
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Nurse Midwife
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Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- 74263, 76706, 77063, 77067, 98960-98962, 99002, G0108, G0109, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190, S0191
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Nurse Practitioner
Physician Assistant
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Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- 74263, 76706, 77063, 77067, 98960-98962, 99002, G0108, G0109, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190, S0191, S9145
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Licensed Addiction Counselor
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Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services
- H0004, H0005, and H2035
- For Medicaid Expansion: H0002, H0031, H2011, H2014, H2017 and H2019
Exceptions are 50% of PPS for
- 90791, 90832, 90834, 90837, 90839, 90840 and H0001
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Licensed Clinical Social Worker
Licensed Professional Clinical Counselor |
Allowed at 75% of PPS
Exceptions are 100% of PPS for Medicaid Expansion:
- H0002, H0004, H0031, H2011, H2014, H2017 and H2019
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Licensed Marriage Family Therapist
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Allowed at 75% of PPS for
- 90785, 90791, 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90853 and H0001
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Licensed Master Social Worker
Licensed Professional Counselor
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Allowed at 65% of PPS
Exceptions are 100% of PPS for Medicaid Expansion:
- H0002, H0004, H0031, H2011, H2014 H2017 and H2019
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Licensed Registered Dietician
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Allowed at 75% of PPS
Exceptions are 100% of PPS for:
97802-97804, 98960 – 98962, G0108, G0109, and S9470 |
Local Public Health Unit
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Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- 74263, 76706, 77063, 77067, J0585-J0588, J2503, J2545, J3396, J7308, J7330, Q2026, Q2028, S0190 and S0191
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Naturopath |
Allowed at 65% of PPS |
Peer Support Specialist |
Allowed at 100% of PPS for H0038 |
Pharmacist |
Allowed at 85% of PPS.
Exceptions are 100% of PPS for:
- Vaccines and administration
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Psychologist
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Allowed at 85% of PPS.
Exceptions are 100% of PPS for
96101-96103, 96116, 96118, 96119, 96120, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171 and H0001
Exceptions are 100% of PPS for Medicaid Expansion:
- H0002, H0004, H0031, H2011, H2014, H2017 and H2019
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