Clarification on Updated Out-of-Network Authorization Requirements Effective Jan. 1, 2020
This email is intended for producers in western Pennsylvania, central Pennsylvania, northeastern Pennsylvania, and West Virginia.
***This email is an update to the initial email that was distributed on Sept. 11, 2019. This email clarifies how the changes to utilization management for out-of-network services will impact commercial and Medicare Advantage groups and members.***
We want to make you aware of an important change regarding out-of-network authorizations that will affect your commercial clients' members.
This change will affect all commercial risk and cost plus members.
Note: ASO is not in scope and is being considered for future buy-up models.
Please note that clients and members will both receive communications around this change before the group’s renewal date, but we know clients may come to you with questions around this change. Please use the information below to help prepare you for any questions clients may have.
Beginning Jan. 1, 2020 at the group renewal date, authorization requirements for out-of-network providers will be enforced for:
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Inpatient Services: All out-of-network inpatient services (both urgent and planned) will require medical necessity review prior to payment.
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Outpatient Services: All services on the prior authorization list* will require medical necessity review prior to payment (exception: services managed by Tivity and eviCore).
Medicare Advantage
Effective January 1, 2020, Highmark will require that out-of-network inpatient and outpatient services be deemed medically necessary prior to payment. Providers or members are welcome to contact Highmark to request precertification of coverage from the plan prior to performing or receiving a service to determine whether or not it would be considered medically necessary.
Frequently Asked Questions
Why are we making this change?
This change will bring consistency to how we manage in-and out-of-network services, and ensure members receive the most medically necessary care. This update will also help members to avoid unexpected costs of out-of-network services, when possible.
How is an out-of-network provider defined?
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A provider who is not contracted with Highmark or contracted with a local BCBSA plan.
How will members be notified of this change?
Members will be notified of this change through targeted communications for those with a past use of out-of-network services for chronic or repeatable conditions.
A broad communication educating all members about their responsibilities when using out of network providers will also be developed and distributed.
Will members receive an updated ID card that contains updated language?
New ID cards will not be reissued to members on a mass basis to reflect the updated language. New ID cards will only be reissued for employee additions or at the discretion of Sales and the client, if there are plan benefit or product changes. The card will then contain new language regarding out-of-network authorization.
Note: There will be members in 2020 who have the new language and members who do not based on the specific circumstances.
There is no contract with out-of-network providers, therefore commercial members have no protection from provider billing if medical necessity cannot be determined (no medical records) or post-service if medical necessity is not found.
Where can commercial members find the list for Prior Authorization for Procedures?
The prior authorization list can be found on the member website by clicking the Coverage tab, and then Medical Benefits.
Questions?
If you have questions, please contact your Highmark Sales Executive or Client Manager.
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