Unit 5: Ohio Healthcare Simplification Act (PA and WV Only)
This unit sets forth provisions of, and procedures and policies resulting from, the Ohio Healthcare Simplification Act (“OHSA”).
This unit applies exclusively to providers located in the State of Ohio and participating with Highmark Plans in West Virginia and/or Pennsylvania.
Applicability
This unit does not apply to self-funded Employee Retirement Income Security Act (ERISA) plans.
Who Should Read This Unit
This unit is intended to act as a reference point for Highmark’s network participating professional and facility providers located in the state of Ohio, excepting pharmacists.
In accordance with the Ohio Healthcare Simplification Act (OHSA), Highmark will not require network providers to provide services for all current or future products offered.
However, if all existing products are not accepted, the OHSA permits a plan to refuse to contract and allows for contract termination if a future product is refused.
Networks
Except as permitted by OHSA, Highmark will not rent or sell networks involving Ohio providers.
Termination for Cause Contract Provisions
Termination “for cause” contract provisions are permitted only for:
- Any lawful reason;
- If a party objects to a material amendment for which there is no resolution, either party may terminate not later than 60 days prior to the effective date of the amendment; or
- Any reasonable provision agreed to by both parties.
For More Information
Please see the termination provisions of your provider contract for additional information.
Notification of Material Changes to Terms of Agreement
Highmark shall furnish providers with 90 days’ notice if it intends to make a material change to the terms of the agreement.
Material changes, as defined by the Ohio Healthcare Simplification Act (OHSA), are amendments that decrease the provider’s payment, change the administrative procedures in a way that may reasonably be expected to significantly increase provider’s administrative expenses, or add a new product.
This section on credentialing applies to all providers subject to the Ohio Healthcare Simplification Act (OHSA).
Forms
Highmark accepts the Council for Affordable Quality Healthcare (CAQH) credentialing application form.
In addition, Highmark West Virginia will accept the State of West Virginia Uniform Credentialing Form and the State of Ohio Uniform Credentialing Form.
Incomplete Information
Highmark will notify providers of missing or incomplete information within 21 days of receipt of application.
Time Frames
All providers who participate with Highmark and whose primary site of service is located in Ohio are required to be credentialed and notified of their credentialing status within 90 days of Highmark receiving a complete or incomplete credentialing application.
State Medical Board
Highmark may accept information from the State Medical Board’s website to the extent that the Board has verified medical education, graduate medical education, and examination history of a physician (or the physician’s status with the educational commission for foreign medical graduates).
For More Information
Please see Units, 1, 2, and 4 in Chapter 3 of this Highmark Provider Manual for additional credentialing information.
Highmark may not include most favored nation clauses in professional provider and non-hospital facility provider contracts.
Most Favored Nation Clause as Defined by OHSA
As defined by the Ohio Healthcare Simplification Act (OHSA), a “most favored nation clause” is one that:
- Prohibits the provider from contracting with another contracting entity to provide health care services at a lower price; or
- Requires the provider to accept a lower payment if the provider agrees to provide health care services to any other contracting entity at a lower price; or
- Requires termination or renegotiation of the existing contract if the provider agrees to provide services to another contracting entity at a lower price; or
- Requires the provider to disclose the provider’s contractual reimbursement rates with other contracting entities.
3.5 Arbitration
Arbitration Available For Certain Contract Disputes
Arbitration for contract disputes for the enforcement of certain rights conferred by the Ohio Healthcare Simplification Act (OHSA) is available for:
- Termination for “for clause” provisions;
- Information required by the OHSA to be included in the contract;
- Material amendments; and
- Sections that:
- Prohibit renting or selling networks;
- Require the provider to provide services for all products offered;
- Require the provider to accept any future product offering;
- Waive the provider’s rights under state or federal law; and
- Prohibit the provider from entering into a contract with any other contracting entity.
3.5 Disclaimers
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
