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This is intended for producers with business in Delaware, Pennsylvania and West Virginia. IMPORTANT CHANGE TO PRIOR AUTHORIZATION REQUIREMENTS We want to make you aware of an important change regarding out-of-area prior authorization/precertification requirements that will affect our mutual clients' members in products that have out-of-area and/or out-of-network coverage.
For commercial fully-insured and Medicare Advantage clients: Beginning August 1, 2022, the following prior authorization requirements will be enforced:
- Outpatient, out-of-area and out-of-network Laboratory services related to genetic testing
- Outpatient, out-of-area and out-of-network Radiation Oncology
- Inpatient and outpatient, out of area and out of network Musculoskeletal surgery and interventional pain management services
On or after August 1, 2022, if any of the above mentioned services performed out-of-area or out-of-network without prior authorization, when required, will be rejected. Highmark may request medical records from the local plan in the state where the services were received and attempt to review the service retrospectively. If we review and later find that the services were not medically necessary, the member may be held liable by the provider for the charges. Member education is important to stress the consequences of not coordinating care with their provider to assure approval has been obtained prior to obtaining services.
For ASO clients: Beginning January 1, 2023, commercial self-insured and claims-billed cost-plus clients will have the ability, upon renewal, to implement the same prior authorization requirements for services performed within Highmark’s footprint (in-area), out-of-area, and out-of-network:
- Outpatient Laboratory services related to genetic testing (Lab)
- Radiation Oncology (RadOnc)
- Inpatient and outpatient Musculoskeletal surgery and interventional pain management services (MSK)
This will allow self-insured and claims-billed cost-plus clients to deploy a consistent and robust utilization management strategy across their membership.
Clients may choose to pay for these products in one of two ways; a la carte activity-based per authorization or via a single per contract per month bundle fee.
A la carte activity based pricing:
- MSK - $110 per authorization
- Lab - $580 per authorization
- RadOnc - $780 per authorization
- RadCard (existing product) $20 per authorization
Single per contract per month bundle fee includes MSK, Lab, RadOnc, and RadCard:
Frequently Asked Questions
What is the definition of out-of-area? Out-of-area services are those performed by a provider outside of the Highmark health plan footprint of Pennsylvania, Delaware, and West Virginia and who is participating with their local Blue Plan. Note: effective January 1, 2023 this definition of OOA will include providers outside Western New York and Northeastern New York.
For example, if a client has a portion of their members who live and receive services in Texas, those services would be considered out of area. Additionally, if a member lives in Pennsylvania, but has a service performed in Ohio, those services would also be considered out of area.
What is the definition of out-of-network? Out-of-network services are those performed by a provider who is not contracted with Highmark or any other blue plan. These services can occur either within Highmark’s footprint or out of area.
Why are we making these changes? This change will bring consistency to our utilization management processes within our footprint, out of area and out of network, ensuring that services members receive are medically necessary and appropriate. It will also enable member engagement in decisions related to their healthcare spending.
How will members be notified of this change? Member communication materials will be available and include the services subject to authorization requirements.
Where can members find a specific list of procedures? Members seeking to understand whether specific services require prior authorization should contact member service at the number on the back of their ID card.
If you have questions, please contact your Highmark Sales Executive or Client Manager. |
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