Unit 2: Authorizations

5.2 Introduction

5.2 Authorization Guidelines

5.2 Services Requiring Authorization

5.2 Federal Employee Program (FEP) Prior Authorization Requirements

5.2 Authorization Request Process

5.2 West Virginia Gold Card Program

5.2 Home Health Authorization Submissions (DE, PA, and WV Only)

5.2 Inpatient Admissions

5.2 Auth Submission

5.2 Concurrent Review

5.2 Retrospective Review

5.2 Time Frames for Authorizations

5.2 Faxable Authorization Request Forms

5.2 Preservice Denials

5.2 Emergency Services

5.2 Experimental/Investigational and Cosmetic Services

5.2 Clinical Trials

5.2 PCP Referral Authorizations (DE Only)

5.2 Prior Authorizations for Non-Participating Providers (PA-FPH)

5.2 New York Regulations (NY Only)

5.2 Disclaimers

5.2 Introduction

Highmark requires authorization of all inpatient admissions, medical and behavioral health. In addition, authorization is required for certain outpatient services, procedures, and durable medical equipment and supplies prior to performing the services or providing the supplies.

Authorization must be requested prior to the initiation of these services in accordance with the member’s plan and Highmark administrative requirements. When requesting an authorization, be sure that the member receives care from a provider who participates in the network associated with the member’s benefit plan. If the member has more than one in-network benefit level, select a provider who participates in the network for the member’s highest in-network benefit level.

If a provider fails to obtain authorizations as required, the member cannot be billed for charges for services that are denied for lack of authorization. However, a provider may bill the member if, prior to service or care, the provider informs the member of failure to obtain authorization and the member agrees in writing to pay for such service or care.

Definition

An authorization is a determination by Highmark that a health care service proposed for or provided to a member is “medically necessary” as that term is defined by the member’s contract. If a service requires authorization, then the provider, and in some cases the member, must contact Highmark to request the medical necessity review. Authorization may also be called precertification, preauthorization, prior authorization, prospective review, preservice review, prior approval, or other similar terms.

Authorization does not guarantee payment. A service or supply will be reimbursed by Highmark only if it is medically necessary, a covered service, and provided to an eligible member.

Medical Necessity means health care and services that are necessary to prevent, diagnose, manage, or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap.

We will reimburse for medically appropriate care that is not more costly than alternative services or supplies at least as likely to produce equivalent results for the person's condition, disease, illness, or injury.

Products Requiring Authorization

All Highmark products, including Medicare Advantage, require that certain services be authorized as a condition of coverage. However, benefits can vary; always confirm authorization requirements under the member’s coverage prior to providing services.

Utilization Decision Making

Highmark makes utilization review decisions based only on appropriateness of care and service and the existence of coverage. They do not reward practitioners, providers, Highmark employees, or other individuals conducting utilization review for issuing denials of coverage or service, nor do they provide any financial incentives to utilization management decision makers to encourage denials of coverage.

5.2 Authorization Guidelines

Authorization review is the process by which services are evaluated according to benefit availability and criteria for medical necessity and appropriateness. Ordinarily, authorization should be in place before services are rendered; therefore, this process is often called "precertification” or “prior authorization.”

Medical appropriateness reviews are conducted to determine the appropriateness of a service. A pre-admission review is performed prior to admission on the elective surgical procedure being performed (NOT level of care), concurrently during an episode of care, and retrospectively to determine that procedures are medically necessary and appropriate for a specific condition. If health services are approved, Highmark will not modify standards or criteria during the same course of treatment.

Provider-Driven Process

The authorization process is provider-driven for all in-network care. This means that it is the network provider's responsibility to obtain authorization for an inpatient admission or for any outpatient services requiring approval.

If services are delivered and authorization is required but not obtained timely, the corresponding claim may be rejected and the member must be held harmless. In order for such a claim to be considered for payment, the provider will need to request a retrospective review and submit the applicable medical records, if applicable.

For HMO, IPA, and POS products, the PCP is responsible for obtaining authorizations for services needed by the PCP’s designated members. If a referral is made to a specialist, the specialist can request an authorization for a service he or she will provide.

Criteria Used

Highmark Medical Policy and Medicare Advantage Medical Policy* are used to assess the medical necessity and appropriateness of health care services.

For inpatient care, Highmark also uses MCG Care Guidelines in the processes for assessing medical necessity and appropriateness of services. The MCG Care Guidelines are applied to assess acute adult, acute pediatric, acute rehabilitative, long-term acute, skilled nursing, and home health services. These criteria are applied in conjunction with applicable Highmark Medical Policy and CMS Medicare Advantage Medical Policy.

For more information on Highmark’s commercial and Medicare Advantage medical policies and criteria used for medical management decisions, please see Chapter 5.1: Care Management Overview. 

Electronic Authorization Requests

Availity® is the preferred method for submitting authorization requests to Highmark. Authorizations may be requested through Availity or by submitting a HIPAA 278 electronic transaction. Electronic authorization requests are the preferred method and are quick and easy to perform.

For a HIPAA 278 transaction, refer to the Provider EDI Reference Guide accessible from the Provider Resource Center:

• Select Claims, Payment & Reimbursement from the left-hand menu, and then Electronic Data Interchange (EDI) Services.
• Select Resources from the menu on the Highmark EDI Trading Partner Business Center home page.

Important! Authorization Is Not A Guarantee of Payment

When an authorization number is provided, it serves as a statement about medical necessity and appropriateness; it is not a guarantee of payment. Payment is dependent upon the member having coverage at the time the service is rendered and the type of coverage available under the member’s benefit plan.

It is the provider’s responsibility to verify that the member’s benefit plan provides the appropriate benefits for the anticipated date of service prior to rendering service. Some benefit plans may also impose deductibles, coinsurance, copayments, and/or maximums that may impact the payment. Providers may consult Availity to obtain benefit information.

When Highmark is not Primary

Authorization requirements apply if a claim will be submitted to Highmark for any portion of payment. Therefore, if the member’s primary insurance is with a commercial carrier other than Highmark, any authorizations required under the member’s Highmark benefit plan are required if a claim will be submitted to Highmark for services requiring authorization.

However, if traditional Medicare is primary, an authorization is required only if:

• The member exhausts his/her Medicare benefit and desires to continue the service;
• The service is not covered by Medicare (e.g., home infusion); or
• The member is admitted to a Veteran’s Administration (VA) facility (applicable to West Virginia only). 

Behavioral Health Benefits

Behavioral health benefits vary by group. In some instances, a group may purchase medical health care coverage through Highmark, but behavioral health care coverage through another company.

To be sure a member has behavioral health care coverage through Highmark, verify eligibility and benefits through Availity® or perform the applicable HIPAA electronic transaction. If you do not have electronic access, call the benefits telephone number on the member’s identification card.

The member's benefit program must provide the specific benefit for the service the member is scheduled to receive. If the member's benefit program does not provide the benefit, the facility will not be reimbursed for the services.

Disclaimer

An authorization is a determination of medical necessity only and does not guarantee coverage or payment. Payment is based on the member’s coverage and eligibility at the time of service.

A service that has been authorized may nonetheless be denied payment if:

• The member is no longer eligible when the service is provided;
• The service is not a covered benefit under the member’s contract; or
• The service actually provided is different from the service authorized.

Medical necessity determinations are not a substitute for the medical judgment of the treating provider. They are for reimbursement purposes only. They do not constitute medical advice or treatment or establish any provider/patient relationship.

Providers must exercise their own independent medical judgment regarding the treatment of their patients who are Highmark members. Highmark encourages providers to communicate openly with patients about their treatment options, regardless of benefit coverage limitations. Responsibility for medical treatment and decisions remains with the member and his or her physician.

Medical Record Review

Highmark reserves the right to request and review medical records for visits whether or not authorization is required. If such review determines that any or all treatments were not medically necessary, were not billed appropriately, or were not performed, a refund will be requested. If a refund is requested, the provider may not bill the member for the services. 

If The Authorization is not in Place at the Time of Service

Ordinarily, the member’s attending physician should have requested a required authorization prior to the member receiving the services. However, if a Highmark member arrives for an appointment for non-emergency services and the required authorization does not appear to be in place, the provider should perform an authorization inquiry in Availity. If not Availity-enabled, call Clinical Services at the phone number for your service area.

Failure to Obtain an Authorization

Failure to preauthorize or pre-certify a service or admission may result in a retrospective review. Highmark has the right to review the service retrospectively for medical necessity and appropriateness, and to deny payment when necessary.

If a retrospective review is performed, and Highmark’s Medical Management & Quality (MM&Q) department determines that the service was medically necessary and appropriate, the claim will be paid.

If MM&Q determines that the service was not medically necessary and appropriate, no payment will be made for the claim. In this situation, the network provider must write off the entire cost of the claim and may not bill the member (except for any non-covered services).

Vendor Delegation and Oversight

Highmark delegates specific Utilization Management functions to a number of vendors. Highmark seeks to align with vendors who are an expert in their field and have attained national certifications.

Our vendors maintain their own UM Program, which is approved by Highmark’s Vendor Joint Oversight Team and reports to the Quality Management Committee. Vendor physicians are involved in our clinical committees upon request.

Utilization Management conducts yearly audits that include a review of policies, procedures, and operational functions of the Utilization Management Department.

File audits are conducted on a quarterly basis.

5.2 Services Requiring Authorization

Highmark commercial and Medicare Advantage products require authorization for all inpatient admissions and select outpatient services, drugs, and equipment. The following circumstances are representative of those services that require an authorization. This is not an all-inclusive list. Benefits can vary; always confirm a member’s coverage prior to providing services.

• Inpatient hospital admissions
• All other inpatient admissions (e.g., skilled nursing facility, rehabilitation, behavioral health, long-term acute care facility)
• Home health care
• Clinical trials
• Hospice
• Transplantation services
• Highmark's List of Procedures/DME Requiring Authorization

Important! Delaware Mandate

Delaware legislation, effective January 1, 2018, puts restrictions on imposing authorization and review requirements on drug and alcohol dependency treatment. Please see Chapter 5.4: Behavioral Health for information.

For complete details of the Delaware mandate, please see Chapter 4.2: Behavioral Health Providers.

Inpatient Admissions

Authorization is required for all inpatient medical services and inpatient levels of behavioral health care. Authorization is required under all Highmark products whenever a member is admitted as an inpatient to any of the following facilities:

• Acute care hospital
• Long-term acute care hospital (LTAC)
• Rehabilitation hospital
• Skilled nursing facility (SNF)
• Mental health or substance abuse treatment facility

Exception: Maternity Care

An authorization is not required for a normal inpatient delivery for maternity care unless clearly designated in a member’s benefit. Normal inpatient delivery in forty-eight (48) hours for vaginal delivery and ninety-six (96) hours for caesarean section.

If the mother and/or baby require an inpatient stay that exceeds these time frames, authorization would be required. In addition, the Clinical Services department should be contacted for any non-routine or emergency admissions for maternity care, such as admissions for hyperemesis, preterm labor, placenta previa, and preeclampsia. 

List of Procedures/ DME Requiring Authorization

Highmark maintains a list of outpatient procedures/services that require authorization. Throughout the year, procedures are added and/or deleted and these changes are communicated to the provider community through Special Bulletins. The list includes services such as:

• Behavioral health intensive outpatient and partial hospitalization (except in New York where a prior authorization is not required for outpatient services)
• Potentially experimental, experimental, and cosmetic procedures
• Select durable medical equipment (DME)
• Select injectable drugs covered under the member’s medical plan
• Some oxygen services
• Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
• Certain outpatient procedures, services, and supplies

To obtain additional information about authorization requirements and to view the all-inclusive and most up-to-date list, please visit the Provider Resource Center. Select Claims, Payment & Reimbursement from the left-hand menu, and then Procedures/Service Requiring Prior Authorization.

For quick access to The List of Procedures/DME Requiring Authorization, click on the Requiring Authorization tab on the Quicklinks bar that spans across the top of the Provider Resource Center:

Note: Certain employer groups may choose to opt out of this requirement. In addition, self-funded accounts, government programs, and other groups with non-standard benefits may have their own lists of services requiring authorization. You must confirm if the requirement is applicable to the member. You can use the Availity® Eligibility and Benefits Inquiry or the applicable HIPAA electronic transaction for benefit verification.

Outpatient Services Provided by Out-Of-Area Blue Plan Providers

As of November 1, 2020, Highmark expanded our prior authorization requirements for outpatient services to include those services provided by out-of-area providers participating with their local Blue Plan. This assures that the care our members receive while living and traveling outside of the Highmark service areas is medically necessary and managed consistently as it is throughout our service areas. 

Out-of-area Blue Plan providers will be required to contact Highmark for prior authorization for services on our List of Procedures/DME Requiring Authorization. Highmark's provider portal, Availity, is enabled to accept authorization requests for outpatient services from out-of-area Blue Plan providers when submitted via their local portals.

Claims for services on the prior authorization list received without authorization will deny and a request for medical records will be sent to the provider’s local Blue Plan.

Authorization Requirements for Out-Of-Network Services for Commercial Products

Effective January 1, 2020, Highmark requires prior authorization for inpatient admissions and also for outpatient services on Highmark’s List of Procedures/ DME Requiring Authorization when a Highmark member with commercial coverage seeks those services from an out-of-network provider. Members seeking services from out-of-network providers will be responsible for working with their provider to assure they are obtaining the necessary authorizations.

An “out-of-network provider” is a provider that is within Highmark’s service area but not participating in the member’s network or an out-of-area provider located outside of Highmark’s service area who is not participating with their local Blue Plan.

The authorization requirements for outpatient services are effective January 1, 2020, for all Affordable Care Act (ACA) individual products. Beginning January 1, 2020, these requirements will also be applied to fully insured small and large groups upon the group’s renewal.

These authorization requirements for outpatient services do not apply to self-insured groups (ASO), the Federal Employee Program (FEP), Pennsylvania’s Children’s Health Insurance Program (CHIP), Medicaid, student health insurance plans (SHIP), and indemnity and comprehensive benefit plans.

Note: These requirements do not apply to outpatient services managed by our partner vendor eviCore.

Medicare Advantage Out-Of-Network Requirements

Effective January 1, 2020, Highmark requires that out-of-network inpatient and outpatient services be deemed medically necessary prior to payment. Providers or members may 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.

Note: These requirements do not apply to outpatient services managed by our partner vendor eviCore.

Speech Therapy

Speech therapy services, including those for Medicare Advantage, require prior authorization. For additional information for Medicare Advantage members, please see Chapter 5.3: Medicare Advantage Procedures.

Physical Medicine Management Program

Information about physical medicine services that require prior authorization can be found on the Provider Resource Center. Select Care Management Programs, and then click on the Physical Medicine Management Program link for details on this program. The program applies to physical and occupational therapy and manipulation services in Pennsylvania and West Virginia. In Delaware, the program is for physical and occupational therapy services.

Advanced Imaging and Cardiology Services

Highmark requires authorization for select advanced outpatient diagnostic imagining procedures. Highmark partners with eviCore healthcare (eviCore) for Highmark’s Advanced Imaging and Cardiology Services Program. This program incorporates a comprehensive, evidence-based clinical review, including predictive intelligence, clinical decision support, and peer-to-peer discussions.

Additional information is available in the Highmark Provider Manual’s Chapter 4.5: Outpatient Radiology and Laboratory. And you can find details of the program on the Provider Resource Center under Care Management Programs.

Radiation Therapy Authorization Program

Additional information on radiation therapy services that require prior authorization can be found on the Provider Resource Center. Select Care Management Programs, and then Radiation Therapy Authorization Program.

Post-Acute Care Management for Medicare Advantage Members

Highmark has a partnership with naviHealth, a national post-acute care management company, to bring a personalized approach to support its Medicare Advantage members. According to patient needs, naviHealth will utilize decision-support technology and its post-acute analytics capabilities to coordinate long-term acute care, inpatient rehabilitation, and skilled nursing facility utilization and will oversee proper care transitions to and from these facilities.

For more information, please see the program page on the Provider Resource Center — select Care Management Programs, and then Post-Acute Care Management for Medicare Advantage Members.

Laboratory Management Program for Molecular and Genomic Testing

Highmark contracts with eviCore to manage molecular and genomic testing to ensure that the genetic lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.

Additional information on authorization requirements is available on the Provider Resource Center — select Care Management Programs, and then Laboratory Management Program.

MSK and IPM Services

Effective October 1, 2018, musculoskeletal surgical (MSK) procedures and interventional pain management (IPM) services require prior authorization under the Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program managed by eviCore. Additional information is available on the Provider Resource Center under Care Management Programs.

5.2 Federal Employee Program (FEP) Prior Authorization Requirements

The Federal Employee Program (FEP) has precertification and prior authorization requirements for the longstanding Standard and Basic options and also for the new FEP Blue Focus product, which is effective January 1, 2019.

Inpatient Admissions

Precertification is required for inpatient hospital, residential treatment center (RTC), and skilled nursing facility admissions. FEP applies a $500 penalty if an authorization is not obtained for inpatient hospital admissions. However, the penalty is imposed on the provider — in the form of reduced payment. The provider may not bill this amount to the member.

Note: Precertification requirements are not applicable to skilled nursing facility admissions for the Basic Option and for FEP Blue Focus since the plans do not have a benefit for skilled nursing facility.

Other Services Requiring Prior Authorization

Prior authorization or notification is also required for certain services for FEP members, as indicated in the table located Here.

For the FEP Blue Focus product, FEP applies a $100 penalty if an authorization is not obtained for any of the services listed below. The penalty is imposed on the provider in the form of reduced payment if a claim is received and the service is determined to be covered and medically necessary based on Medical Review. The provider may not bill this amount to the member.

For a full list of services that require prior authorization, go the Provider Resource Center click Claims, Payment & Reimbursement, and select Procedures/Service Requiring Prior Authorization.

Confirming Member Benefits

You can confirm FEP member eligibility and benefits, including prior authorization requirements, via Availity®. You can also call the FEP Provider Service Department for your service area as follows:

• Pennsylvania: 1-800-258-8809
• Delaware: 1-800-572-2872
• West Virginia: 1-800-344-5245
• New York: 1-800-234-6008

Requesting Authorization

Please follow the guidance below for calling the FEP Provider Service department for authorizations for FEP members.

• For outpatient/professional services that require authorization, please contact your local Highmark plan.
• For inpatient admissions, medical and behavioral health, the services should be authorized by the Blue Cross plan where the services are being received as follows:
  • Pennsylvania’s Western & Northeastern Regions, Delaware, and West Virginia – Highmark participating providers should contact their local Highmark plan for authorization for inpatient admissions.
  • Pennsylvania’s 21-county Central Region – providers participating with Capital Blue Cross or Independence Blue Cross would request authorization for inpatient admissions from Capitol Blue Cross.

For More Information

You can find a wealth of information to assist you in servicing FEP members at fepblue.org.

Additional information related to the Federal Employee Program is also available in the following units of the Highmark Provider Manual:

• Chapter 2.3: Other Government Programs for background information, FEP products, and membership
• Chapter 5.1: Care Management Overview for information on accessing FEP Medical Policy (under section titled “Criteria for Medical Management Decisions”)
• Chapter 6.4: Professional (1500/837P) Reporting Tips for special tips on claim submission for FEP members

5.2 Authorization Request Process

Authorization requests should be submitted at least 14 days in advance prior to a planned admission or service, when possible, or as soon as the intended admission or service is known.

For emergency (urgent, unplanned) admissions, the hospital is asked to obtain an authorization within 48 hours of the admission or as soon as the necessary clinical information is available.

For admissions related to childbirth, the provider must contact Highmark within 48 hours after an emergency admission or for lengths of stay longer than 48 hours after a vaginal delivery or ninety-six (96) hours after a cesarean section (C-section) delivery.

Reminder: Verify Eligibility & Benefits

Providers are reminded to always verify a member’s eligibility and benefits, including the authorization requirements, prior to rendering services. It is the provider’s responsibility to confirm that the member’s benefit plan provides the appropriate benefits for the anticipated date of service.

You can verify benefits electronically quickly and easily via Availity’s Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.

Before You Begin…

Prior to submitting an authorization request, whether electronically or by telephone, please have the following information available:

• Patient’s general information (name, age, gender, etc.)
• Member ID number
• Medical history
• Any comorbidity
• All pertinent medical information (test results, prior treatment, etc.)
• Presenting symptoms
• Acuity
• Diagnosis
• Service to be performed, including admission or procedure dates and location
• Name of any other health care providers involved in the care
• Proposed length of stay and frequency or duration of services
• Treatment plan and goals
• Psycho-social issues impacting care
• Discharge plan

Note: The Highmark reviewer may request additional information. Requests may be denied for lack of information. 

Electronic Submission Preferred

Electronic submission is the preferred method for requesting authorization. If Availity®-enabled, the request must be submitted via Availity.

Process

The authorization request process is as follows:

*The EDI Reference Guide is accessible from the Provider Resource Center. Select Claims, Payment & Reimbursement, and then Electronic Data Interchange (EDI) Services. Select Resources from the EDI Training Partner Business Center home page.

Home Health Authorization Requests

Home health care providers must use Availity® to submit authorization requests. Please see the next section of this unit — Home Health Authorization Submissions.

If you are not Availity-enabled, home health care providers can fax requests using the Home Health Precertification Worksheet or make their requests by calling Clinical Services.

The worksheet is also accessible on the Provider Resource Center — select Forms from the left-hand menu, and then Authorization Forms. 

Telephone Requests

You may contact Clinical Services by calling the applicable phone number for your service area.

Pennsylvania:

• Western Region:
  • Facilities: 800-242-0514
• PA Central Region:
  • Facilities: 866-803-3708
• PA Northeastern and Southeastern Regions:
  • Facilties: 800-452-8507
• Medicare Advantage:
  • PA Medicare Advantage Freedom Blue PPO: 866-588-6967
  • Community Blue Medicare HMO: 888-234-5374
  • Community Blue Medicare PPO and Plus PPO: 866-588-6967
  • Security Blue HMO (Western Region only): 866-517-8585

Note: Professional providers should call the appropriate Medicare Advantage program number.

Delaware:

• Medical Services: 800-572-2872

West Virginia:

• Highmark West Virginia Products for Medical: 800-344-5245
• Medicare Advantage Freedom Blue PPO: 800-269-6389

New York:

• Utilization Management: 844-946-6263
• After hours expedited appeals or urgent access to medical issues: 844-946-6263*

Behavioral Health Services:

• PA Northeastern and Western Regions: 800-258-9808
• PA Central and Southeastern Regions: 800-628-0816
• Delaware: 800-421-4577
• West Virginia: 800-344-5245; Freedom Blue PPO: 800-269-6389
• New York: 844-946-6264

*Highmark Blue Cross Blue Shield of Western New York and Highmark Blue Shield of Northeastern New York Business Hours:

• A nurse or physician is available to take your call from 8:15 a.m. until 5 p.m.
• A staff member will identify themselves by name, title, and organization name when initiating or returning calls regarding Utilization Management issues.
• Calls regarding inquiries will only be received during normal business hours 

Out-Of-Network Providers

To determine the authorization requirements under a member’s benefit plan, out-of-network providers may contact Highmark by calling the Member Service phone number on the back of the member’s identification card.

To obtain authorizations for Highmark members with commercial coverage, out-of-network providers are directed to contact Highmark Clinical Services at the Utilization Management phone number on the back of the member’s identification card.

Important! Federal Employee Program (FEP)

Please see the Federal Employee Program (FEP) Prior Authorization Requirements section of this unit for guidance for calling for authorizations for FEP members.

5.2 West Virginia Gold Card Program

Highmark Blue Cross Blue Shield’s Gold Card Program is an exemption-based program established to recognize providers identified as consistently following medical necessity guidelines through review of past performance by rewarding them with a greater level of self-management.

Effective January 1, 2024, West Virginia providers can qualify for the Gold Card Program for specific procedures that require prior authorization if they meet the requirements as outlined below. Providers meeting the requirements will not be required to submit prior authorizations in the specified calendar year. During this period, Highmark Blue Cross Blue Shield will only require a pre-notification (no clinical information required) for the qualifying procedure(s), unless requested for retrospective audits.

Background

The Gold Card Program was developed in accordance with West Virginia Senate Bill 267, which was passed on March 8, 2023. The purpose of the bill is to establish universal guidelines related to prior authorizations.

How to Qualify

A provider can qualify for the Gold Card Program if the following requirements are met:

• The provider performs an average of 30 procedures per year; and
• In a six-month time period during that year, the provider receives a 90% final prior approval rating.

The procedures are counted toward the 30-procedure threshold only when rendered by a West Virginia health care practitioner for Highmark Blue Cross Blue Shield West Virginia commercial fully insured, ACA, or ASO Opt-in members. Please utilize Highmark's provider portal, Availity, to readily identify the member’s coverage.

Notification of Qualifying Status

The Gold Card Program is a calendar year program. If you qualify for the program, you will be notified by letter, which will be delivered via U.S. Mail. The letter will provide additional details pertaining to your exemption or "Gold Card" status.

Note: If you do not receive a notification letter by the end of December and believe you qualify for the program, please contact Highmark at GoldCardInquiries@highmark.com.

Requirements for Program Participants

While participating in the program, you must continue to adhere to Highmark Blue Cross Blue Shield medical policy and medical necessity requirements, which are periodically assessed for ongoing compliance.

Although you will not be required to submit clinical information for the qualifying procedure(s) while a program participant, you are still required to pre-notify Highmark Blue Cross Blue Shield of upcoming procedures by submitting base-level demographic information, including:

• Patient name, date of birth, ID/Unique Member Identifier (UMI) — with prefix
• Start of care date
• Procedure code(s)
• Primary diagnosis code
• Blue Shield ID
• NPI

This information is submitted to Highmark Blue Cross Blue Shield using Availity. When you submit the information, you will receive a reference number for qualifying procedures as long as you remain qualified for the Gold Card Program.

If you need assistance regarding electronic authorization submissions, you can email us at ElecAuthSubmit@highmark.com.

Important!

This exemption to submission of clinical information for services requiring authorization only applies to the specific procedure(s) for which you qualified under the Gold Card Program. You are still required to submit prior authorization requests, as usual, for all other procedures and Highmark members, as applicable.

Services not Included in The Program

The following services are not included in the Gold Card Program:

• Unplanned inpatient stays
• Pharmaceuticals (including medical injectable drugs)
• Durable medical equipment
• Home health
• Post-acute care, including:
  • Skilled nursing facilities
  • Long-term acute care
  • Inpatient rehabilitation facilities
• Other considerations
  • Some services must undergo a review to determine if the service is a covered benefit. Non-covered services are out of network services or procedures, experimental treatment, or non-covered benefits.

Retrospective Audits

Program participants must adhere to Highmark's medical policy and medical necessity requirements to remain eligible for the Gold Card Program. This exemption is subject to internal auditing at any time by Highmark.

Providers will be notified which cases have been selected for audit. These audits are conducted to ensure continued adherence to medical necessity criteria in accordance with medical policy.

This exemption may be rescinded if the health care practitioner is not performing services or procedures in conformity with Highmark Blue Cross Blue Shield's benefit plan, if there is substantial variance in historical utilization, or if other anomalies are identified on internal audit. Highmark will notify you of the outcome of internal audits. If applicable, a letter detailing the rationale for revocation of an exemption will be provided.

5.2 Home Health Authorization Submissions (DE, PA, and WV Only)

Participating home health care providers in Delaware, Pennsylvania and West Virginia must use the home health care authorization request submission process through Availity®, Highmark's provider portal. This process is applicable for all commercial and Medicare Advantage products.

Requirements

Using Availity, the following is required to be submitted:

• An Outcome and Assessment Information Set (OASIS) File upload
• The CMS-485 form

Helpful Resources Available

Please review the following webinar and helpful documents for additional information:

• Home Health Process Change Guide
• Home Health Authorization FAQs
• Home Health Authorization Tips: OASIS File Overview

These resources are also available on the Provider Resource Center. Select Provider Training from the main menu, and then Provider Training again. Scroll to the Informational Training and Documentation section -- Home Health Authorizations is the third bullet in this category.

Important! Always Verify Eligibility and Benefits

When an authorization is obtained, it is not a guarantee of payment. The member must have active coverage at the time of service and must also have the benefit for the service to be provided. Therefore, it is important to verify the member’s eligibility and benefits through Availity or through the applicable HIPAA electronic transactions.

Provider Service Center

For general questions and inquiries about the new home health care authorization process, please contact the facility Provider Service Center. To find the appropriate Provider Service Center for your region, Click Here.

5.2 Inpatient Admissions

The purpose of the authorization review is to determine whether the services being requested are medically necessary and appropriate and are being delivered in the most appropriate setting. Authorization review assists Care and Case Managers in identifying potential candidates for post-discharge case management or the Blues On Call condition management programs.

Authorization Request Time Frames

Authorization is required for all in-network inpatient medical services and inpatient levels of behavioral health care. Authorization requests should be submitted at least fourteen (14) days in advance prior to a planned admission, when possible, or as soon as the intended admission is known. Authorization for planned admissions must occur no later than the date of admission.

Emergency Inpatient Admissions

For emergency (urgent, unplanned) admissions, the facility is asked to obtain an authorization within forty-eight (48) hours of the admission or as soon as the necessary clinical information is available (except in New York where notification is required by an authorization is not).

Submitting A Request for Authorization

Facilities should submit authorization requests for medical and behavioral health inpatient admissions via Availity®. Please see the next section of this unit for information.

If either Availity or the authorization request application is unavailable, facilities may make their requests by contacting Clinical Services via telephone at the applicable phone number.

Out-of-Network Services

Some members have coverage under a benefit plan (e.g., PPO) that provides benefits for services received from a provider outside of the network associated with their Highmark product.

The authorization requirement does not apply to such services, except for inpatient admissions to a hospital, skilled nursing facility, rehabilitation hospital, and long-term acute care. These services are reimbursed according to the terms of the member's benefit plan, including any applicable member liability.

Reminder: Benefit Verification Required

While not all services require authorization, availability of benefits under the member's benefit plan is required in order for a service to be reimbursed by Highmark. Availability of benefits can be verified through Availity.

Transfers Between Hospitals

Transfer of a member from one facility to another requires authorization from Clinical Services. The table below identifies which facility has responsibility for obtaining authorization for transfers between hospitals:

Behavioral Health

Some processes vary slightly for behavioral health services. For additional information specific to behavioral health services, please see Chapter 5.4: Behavioral Health.

In addition, step-by-step instructions for submitting behavioral health authorization requests via NaviNet are available in the Behavioral Health ACM Authorization Submission Manual. This manual is also available on the Provider Resource Center under Education/Manuals.

Special Process for Medicare Advantage Members

The Centers for Medicare & Medicaid Services (CMS) requires that members with coverage under original Medicare or a Medicare Advantage plan are fully aware of their right to appeal a discharge decision. Therefore, a special process will apply to these members. These processes begin when a Medicare Advantage member is admitted to an inpatient level of care in an acute care hospital, long-term acute care hospital, skilled nursing facility, inpatient psychiatric hospital/unit, or acute rehabilitation hospital/unit.

For more information on these special processes for Medicare Advantage members, please refer to Chapter 5.3: Medicare Advantage Procedures.

5.2 Auth Submission

Authorization Submission

Highmark provides an automated process via Availity which allows facilities to submit authorization requests for medical and behavioral health inpatient care and inpatient/post-acute transfers using interactive MCG Care Guidelines. Availity can also be used for submitting behavioral health intensive outpatient and partial hospitalization authorization requests.

Important: Observation Services

Availity is not used for observation services since observation services do not require authorization.

However, if it becomes clear that the member requires inpatient admission, the hospital is asked to obtain an authorization within forty-eight (48) hours of inpatient admission or as soon as the necessary clinical information is available.

Highmark's Expectation of Facilities

Highmark expects that Availity-enabled facilities will submit all medical and behavioral health inpatient authorization requests, inpatient/post-acute transfer requests, and behavioral health intensive outpatient and partial hospitalization authorization requests for Highmark members via Availity.

Facilities are also expected to provide consistent and timely completion of the admission and discharge surveys, including entry of the discharge date.

Monitoring The Process

Based on monitoring patterns of the facility's use and submissions, Highmark has the right to perform on-site educational audits and discuss findings with the appropriate hospital staff.

Admission Questions

Admission questions are incorporated into MCG Care Guidelines. The facility should be prepared to provide the following information during the initial request for authorization of an inpatient admission:

• Patient history and any co-morbid conditions
• Re-admissions within thirty (30) days
• Social situation or Social Determinants of Health to be aware of
• Any special needs
• Any assistance needed from Clinical Services in discharge planning

Important Benefit Reminder

An authorization means that the requested service has been determined to be medically necessary and/or appropriate.

It does not mean that the requested service is covered under the member's benefit plan. Payment is contingent on the availability of benefit coverage for the services rendered and the eligibility of the patient.

Discharge Planning Information Survey

Hospitals are also responsible for completing the Discharge Planning Information Survey during an inpatient admission of five (5) or more days, the survey can also be completed at or immediately following discharge.

For more information, please see the “Discharge Planning” section of this unit.

Post-Acute Transfers

Acute care facilities also submit authorization requests via Availity for post-acute transfers to long-term acute care hospitals, acute rehabilitation hospitals, and skilled nursing facilities.

Submitting authorization requests through Availity for these transfers follows a similar process to the steps which are used for acute inpatient hospital admissions.

Discharge Survey

The Discharge Planning Information survey for the acute care stay must be completed at discharge. 

Time Frames for Post-Acute Transfer Requests

Post-acute transfer requests may be entered according to the following schedule: 

Continuity of Care

To ensure continuity of care, facilities are asked to notify the member's primary care or preferred physician about any services that he or she receives during the inpatient stay.

This step taken by the facility enables the primary care or preferred physician to make any subsequent treatment decisions on a more fully informed basis.

Special Procedures for Medicare Advantage Members

The Centers for Medicare & Medicaid Services (CMS) has established procedures to ensure any member with coverage under original Medicare or Medicare Advantage plans has the opportunity to appeal a discharge decision with which he or she disagrees. This process begins when a Medicare Advantage member is admitted to an inpatient level of care and requires additional action prior to discharge.

Note: For more information on these special processes for Medicare Advantage members, please see Chapter 5.3: Medicare Advantage Procedures.

Additional Resource for Behavioral Health

The Behavioral Health ACM Authorization Submission Manual provides instructions for submitting authorization requests through NaviNet for behavioral health inpatient, intensive outpatient, and partial hospitalization services. This manual is available under Education/Manuals on the Provider Resource Center in all service areas.

5.2 Concurrent Review

When Is Concurrent Review Conducted?

Highmark may conduct concurrent review, also known as continued stay review, for any services as determined by Highmark, including, without limitation, all behavioral health services and medical care at hospitals, skilled nursing facilities, long-term acute care facilities, rehabilitation facilities, and any other facilities as noted by Highmark regardless of whether a per diem or DRG facility.

Components of Concurrent Review

The concurrent review process for medical services can be initiated by either the facility or by the Clinical Services department. The process for medical services involves three components:

1. Contact between Clinical Services and the facility
2. Sharing of relevant clinical information
3. Application of the appropriate clinical standards to determine whether the member’s inpatient services should be extended

During the concurrent review conversation, the facility should be prepared to provide relevant information about the member’s clinical signs and symptoms, continuing treatment, and discharge plans.

The Decision Process

Based on the information provided by the facility, the Clinical Services nurse reviewer applies the relevant criteria and determines whether to extend the member’s care or to offer an alternative level of care. Concurrent review cases that meet criteria will be approved.

If the clinical staff cannot approve the case, it is referred to a physician reviewer to determine the need for the continuation of services.

Approval Notification

The requesting entity is notified verbally of the approval decision by the care manager or physician reviewer within designated regulatory time frames.

In addition, approval notifications are provided electronically to all Availity-enabled providers. Approval letters are sent to commercial and indemnity members as well as providers without electronic connectivity.

Denial Notification

If the member does not meet the criteria for continued stay, the Clinical Services staff will contact the entity requesting the review to explore and facilitate alternative care as appropriate. The member’s needs, as well as the local delivery system, will be considered in making a determination.

In accordance with legal and regulatory requirements, the member and/or facility will be notified of a denial both verbally and in writing. The verbal notification will include information about the right to appeal the decision. The written notification will also include the member’s appeal rights.

Medicare Advantage: When Continued Stay is not Approved

When a concurrent review results in a denial and a Medicare Advantage member disagrees with the decision to be discharged from inpatient care, the member may request a review.

Highmark delegates responsibility to the facility to issue the Detailed Notice of Discharge (or “Detailed Notice”) form to the member. This form gives a detailed explanation of the discharge decision as well as a description of any applicable Medicare and/or Medicare Advantage coverage rules, policies, or rationales which support the decision.

Note: For more information, please refer to Chapter 5.3: Medicare Advantage Procedures.

Time Frame

Decisions regarding inpatient concurrent review are made within twenty-four (24) hours of receipt of the request in order to comply with strict decision-making time frames imposed by regulatory/accreditation standards.

All relevant information must be provided by the facility at the time of the request. Timely submission of the relevant clinical information will avoid any unnecessary denials due to lack of information.

Additional Components of Concurrent Review

Medical necessity, quality, utilization review, and utilization management requirements, as well as all other applicable administrative requirements as determined by Highmark, as applicable to all payment methodologies including, without limitation, DRG-based payments, are also applicable to all outlier determinations and outlier payments.

If the member does not meet the applicable criteria as determined by Highmark for a continued stay based on such aforementioned criteria, then those days not meeting the concurrent review requirements for a continued stay will not be included:

• in the count for day outlier status.
• in the calculation for cost outlier status for charges related to tests, procedures, room and board, etc.

Also, is the admission is determined by Highmark to not be medically necessary and appropriate for acute care, the admission will be downgraded and paid at the observation rate or the outpatient methodology, as applicable.

Note: Highmark will apply the applicable criteria as determined by Highmark for a continued stay against review of the entire length of stay to ensure outlier payments are not made for care that is not medically necessary and appropriate, and/or at the appropriate level of care.

Retrospective Review

Facilities are reminded that Medical Management & Quality (MM&Q) may conduct a retrospective review whenever authorization or continued stay certification was required but not obtained. A retrospective review may also be conducted when Highmark receives a claim that includes outlier days.

Behavioral Health

For more information on concurrent review for behavioral health, please see Chapter 5.4: Behavioral Health.

5.2 Retrospective Review

Retrospective review is the assessment of the appropriateness of health care services after the services have been rendered to a member and completed without prior authorization from Medical Management & Quality (MM&Q). Retrospective review is also known as “post-service review.”

How to Request

To request a retrospective review of an inpatient admission or an outpatient medical service provided without the appropriate authorization, a facility should follow these steps:

Time Frame

Retrospective reviews are completed within thirty (30) calendar days of receipt of the facility’s request. If MM&Q requires additional information, the request will be made within forty-eight (48) hours after receiving the request for retrospective review.

Behavioral Health

For more information on retrospective review specific to behavioral health services, please refer to Chapter 5.4: Behavioral Health.

5.2 Time Frames for Authorizations

Preservice Determinations

For preservice authorization requests, Highmark will provide notification of our determination as soon as possible, taking into account the member’s health condition, but no later than:

• Pennsylvania and Delaware:
  • Seventy-two (72) hours after receipt of the request in cases involving urgent care; or
  • Fourteen (14) calendar days after receipt of the request in non-urgent cases.
• West Virginia:
  • Two (2) calendar days after receipt of the request in cases involving urgent care; or
  • Seven (7) calendar days after receipt of the request in non-urgent cases.

A case involving urgent care is one in which making a determination under standard time frames could seriously jeopardize the member’s life, health, or ability to regain maximum function; or, in the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that could not be adequately managed without the care or treatment that is the subject of the request. If a physician indicates a case is one involving urgent care, it would be handled as such.

For non-urgent cases, Highmark may extend the time frame one time by up to fourteen (14) days (except in West Virginia where an extension of 7 business days will be offered). For products other than Medicare Advantage, if the extension is necessary because the member failed to submit information needed to make the determination, we will afford the member at least forty-five (45) days to provide the specified information.

Preservice Determination

Non-Urgent Care Claims:

When a pre-service claim is submitted for non-urgent care services, a decision is made within three business days of obtaining all necessary information for pre- service claims

Urgent Care Claims:

When a pre-service claim is submitted for urgent care services, a decision is made 72 hours after receipt of request.

The member or the member's designee and the member's health care provider will be notified about all approvals or denials for either urgent care or non-urgent care claims by telephone and in writing. 

Concurrent Review Determinations

For requests to extend a current course of treatment previously authorized, Highmark will provide notification of our determination as soon as possible, taking into account the member’s health condition, but no later than:

• Twenty-four (24) hours after receipt of the request in cases involving urgent care, provided that the request was received at least 24 hours before the expiration of the currently authorized period or treatments; or
• Within the time frames for preservice determinations in non-urgent cases.

If Highmark reduces or terminates authorization for a previously authorized course of treatment before the end of the period or number of treatments originally authorized, we will issue the determination early enough to allow the member to appeal and receive a decision before the reduction or termination occurs.

Concurrent Review Determinations

A decision is made within 24 hours or one business day (whichever occurs first) after receipt of request for concurrent review determinations.

Notification for approvals and denials are made to the member or the member's designee, which may be satisfied by notice to the member's health care provider, by telephone and in writing.

Retrospective Review Determinations

For retrospective reviews, Highmark will provide notification of our determination within thirty (30) calendar days of receipt of the request. If Medical Management & Quality (MM&Q) requires additional information, the request will be made within forty-eight (48) hours after receiving the request for retrospective review.

This 30-day time frame may be extended one time for up to fifteen (15) days. If this extension is necessary because the member failed to submit information needed to make the determination, we will afford the member at least forty-five (45) calendar days to provide the specified information. 

Notification

If an authorization is granted, Highmark will notify the member and requesting provider within the required time frame for the type of review requested. The notification will include a reference number that the provider can use in referencing the authorization.

In concurrent review cases, notification of the authorization to extend services will include the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

If the authorization is denied, Highmark will issue written notification to the member and requesting provider (except in New York where verbal and written notification will be sent to the member and requesting provider). The written notification will include:

• The principal reason(s) for the denial;
• Reference to the plan provision on which the determination is based;
• In the case of denials for lack of information, a description of any additional information necessary to make the determination and an explanation of why it is necessary;
• A description of procedures and time frames for appealing the denial internally and externally, as applicable;
• A statement that a copy of the clinical review criteria relied upon will be provided free of charge upon request; and
• A statement that an explanation of the scientific or clinical basis for the determination as it relates to the member’s medical condition (clinical rationale) will be provided free of charge upon request.

5.2 Faxable Authorization Request Forms

Highmark is continuously taking steps to improve our internal processes to provide quick and efficient service when processing authorization requests.

While the preferred method to submit authorization requests continues to be through Availity®, there are certain instances when Highmark allows requests to be made via fax.

Forms

To locate faxable precertification/authorization forms, go to the Provider Resource Center — select Forms, and then Authorization Forms. For the Behavioral Health fax template, select Forms, and then Behavioral Health Forms.

Fax Forms One Time

An authorization request form should be faxed to Highmark only once. Because of the high volume of requests being submitted into Highmark, the request form may not be immediately loaded and viewable in our system. Re-faxing an original authorization request form will only add to the overall volume of requests being received, which can result in longer overall response times.

Use The Appropriate Form

If you are faxing an authorization request to Highmark, please be sure to use the appropriate authorization request form. The forms vary based on the type of clinical services being requested.

Time Frames: Urgent Vs. Non-Urgent

Highmark remains committed to handling authorization requests within the required regulatory time frames. It is important for providers to submit timely requests well in advance of the patient's anticipated date of service to allow for adherence to the following regulatory time frames:

• Urgent concurrent requests are completed within 24 hours of receipt.
• Pennsylvania and Delaware:
  • Urgent requests are completed within 72 hours of receipt.
  • Non-urgent requests are completed within 14 days of receipt.
• West Virginia:
  • Urgent requests are completed within two calendar days of receipt.
  • Non-Urgent requests are completed within seven calendar days of receipt. 
• New York:
  • Urgent requests are completed within 72 hours of the receipt of the request
  • Non-Urgent requests are completed within three business days of obtaining all necessary information for pre-service claims

Tips

Wait times for authorization requests can either be eliminated or reduced by adhering to the following guidelines:

• Always ensure that the authorization submission includes all required information, including applicable diagnoses and procedure codes.
• When calling Highmark, please have all necessary member and clinical information available to allow for the fastest completion of the call.
• Authorization requirements have been suspended for certain procedure codes. Before submitting an authorization request, check Availity first to see if an authorization is still required.
• Outpatient authorization requests have a 60 day window. Service date changes do not need to be communicated to Highmark as long as they are within the original 60-day time frame.

Use Availity for Status Updates!

Please use Availity to check on the status of your authorization request, as the most up-to-date status will be viewable there.

If you are not yet Availity-enabled, go to the Register and Get Started with Availity Essentials webpage.

5.2 Preservice Denials

At times, providers may encounter situations in which a claim for services provided to a Highmark member is denied because medical necessity criteria were not met. Guidelines have been developed to identify when a Highmark commercial member can be billed for services rendered in such situations.

Guidelines

When services are denied in advance of being rendered, the member must be notified and given the option to cancel the services or proceed with the services as planned.

The Highmark member cannot be billed for the denied services unless the provider has given advance written notification informing the member that the specific service may be deemed not medically necessary or not covered by the member's benefit plan and providing an estimate of the cost. The member must agree in writing to assume financial responsibility before receiving the service.

Note: Medical policy allows a provider to bill the member for services that are deemed to be experimental or investigational. In these cases, providers need to ensure that the member understands that he or she is personally liable for the cost of services that are considered to be experimental or investigational.

Preservice Denial Defined

A preservice denial occurs when a provider informs a member that a specific requested service cannot be provided or continued due to lack of medical necessity or because the service is a non-covered benefit.

If the member accepts the provider’s decision, a preservice denial is not necessary. If the member continues to request the service after being informed that is it non-covered, a preservice denial notification is needed.

This conversation must occur before the service is provided and the claim is submitted. A preservice denial notification cannot be issued for services already received.

Specific to Service to be Provided

The preservice denial notification is specific to the service to be provided and may not be used to secure a routine or “blanket” acceptance of financial responsibility by the Highmark member. 

Requirements

The member must agree in writing to assume financial responsibility in advance of receiving the service. Each of the following conditions must be met:

• Written notification was provided to the member before the service was rendered, indicating the specific service to be received may be denied
• The notification included an estimate of the cost
• The member agreed in writing, before the service was rendered, to assume financial liability for the services
• The signed agreement is maintained in the provider’s records

No Specific Form Required

No specific form is required or recommended for documenting such a conversation with a member. However, the form must do all of the following:

• Identify the proposed services specifically;
• Inform the member that the services are not deemed to be medically necessary or are experimental/investigational;
• Provide an estimate of the cost; and
• Require the member to agree in writing, in advance of receiving a service, to assume financial responsibility for the service.

Purpose of The Preservice Denial Notification

The purpose of a signed agreement is to document that: (a) a provider has had a conversation with the member regarding lack of coverage and the estimated out-of-pocket expense the member will incur; and (2) the member agrees in writing to be financially responsible for the cost of the service.

Appealing Preservice Denials

If the Highmark member has questions about the preservice denial notification or questions about his or her appeal rights, please tell them to call Highmark Member Services at the telephone number listed on their Member ID card.

Member Later Reconsiders

If the member agrees with the provider’s decision not to supply the service at the time of the visit but later reconsiders and decides that he or she wants to have the service, this is a preservice denial.

Important! Medicare Advantage Requirements

The preservice denial requirements for Highmark’s Medicare Advantage members differ from the requirements for Highmark commercial members.

For information specific to Medicare Advantage members, please refer to the section on “Preservice Organization Determinations” in Chapter 5.3: Medicare Advantage Procedures.

5.2 Emergency Services

Introduction

Highmark Blue Cross Blue Shield of Western New York and Highmark Blue Shield of Northeastern New York do not preauthorize emergency services or deny emergency care on a retrospective basis. However, we may identify specific diagnosis to pend for medical review to determine if rationale to seek care in an emergency room setting meets the intent of the New York State Prudent Layperson Law. After review by a physician, Highmark New York will treat identified non-emergency care as an adverse determination and all provisions of Adverse Determination Policy will be applied.

Emergency services, including Comprehensive Psychiatric Emergency Program (CPEP), Office of Mental Health/ Office of Alcoholism and Substance Abuse Services (OMH/OASAS), Crisis Intervention, and OMH/OASAS specific non-urgent ambulatory services are not subject to prior approval.

Emergency Care Defined

"Emergency condition” means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in

1. Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy;
2. Serious impairment to such person’s bodily functions;
3. Serious dysfunction of any bodily organ or part of such person; or
4. Serious disfigurement of such person.

Definition: Prudent Layperson

A prudent layperson is one who is without medical training and who draws on his or her practical experience when deciding whether emergency medical treatment is needed.

Reimbursement of Emergency Services

Emergency services are reimbursed without authorization in cases where a prudent layperson believed that an emergency medical condition existed.

If the emergency condition results in an inpatient admission, the hospital is asked to obtain an authorization within forty-eight (48) hours of the admission or as soon as the necessary clinical information is available (except in New York where a notification is required but an authorization is not).

Emergency Transportation

Emergency transportation and the related medical emergency services provided by a licensed ambulance service are considered to be emergency care and, therefore, are covered without authorization.

5.2 Experimental/Investigational and Cosmetic Services

Highmark maintains policies and procedures to ensure that all services identified as or potentially considered experimental/investigational or cosmetic are reviewed and analyzed on an individual basis.

Definition: Experimental/ Investigational

The term experimental/investigational applies to the use of any treatment, service, procedure, facility, equipment, drug, device, or supply (intervention) which is determined by Highmark or its designated agent not to be medically effective for the condition being treated.

Highmark Medical Policy

Highmark determines an intervention to be experimental/investigational based on one or more of the following reasons:

• The service does not have FDA approval;
• Based on scientific evidence, the service does not impact or improve health outcomes;
• Scientific evidence does not demonstrate the efficacy of the service; and/or
• The service is still being performed in a clinical trial setting with no longterm outcomes available.

Note: Providers need to always follow Highmark Medical Policy. To access medical policies, select Claims, Payment &  Reimbursement from the main menu on the Resource Center, and then Medical Policy.

Definition:Cosmetic

The term cosmetic applies to procedures performed to improve an individual’s appearance and not to improve or restore bodily function.

Precertification Requirements

All services or procedures identified as or potentially considered as experimental/investigational or cosmetic are to be sent to Clinical Services for review. This should occur prior to beginning the treatment.

Physician Review

The care managers refer all requests for potentially experimental/investigational or cosmetic services to the Physician Advisor Office. This step is undertaken to ensure individualized clinical analysis of the requested service and to ensure that every case is reviewed by a physician reviewer.

Questions regarding these services or this process can be directed to Clinical Services by calling the Provider Service Center phone number for your service area.

Appeal Rights

If the physician reviewer determines that a request is either cosmetic or experimental/investigational, a care manager will verbally or electronically notify the provider of the determination and the availability of appeal rights. A denial letter is sent to the member (or the member’s representative), the provider and/or facility. The denial letter will include the member and provider appeal rights.

Both the member and the provider can appeal a denial decision regarding services which are determined to be experimental/investigational or cosmetic in nature.

Note: For information about appeals, please see Chapter 5.5: Denials, Grievances, and Appeals.

5.2 Clinical Trials

Definition

Clinical trials are research studies designed to evaluate the safety and effectiveness of medical care. They are key to understanding the appropriate use of medical interventions of all types.

Verify Benefits

Certain clinical trials may be covered under a member’s benefit plan. Others are covered under the Medicare program.

To determine if benefits are available for a particular clinical trial, providers should check the member’s benefits through Availity. If Availity is unavailable, facilities should contact the Provider Service Center.

Provider Responsibility

When requesting services connected to a clinical trial, it is the responsibility of the provider participating in the trial to furnish Clinical Services with all the necessary information concerning the clinical trial itself as well as the clinical status of the member.

If appropriate, the Clinical Services reviewer will notify the provider about whether the service should be billed to Highmark (i.e., when the member’s benefit plan covers it) or to the Medicare program (i.e., the member’s benefit plan does not cover it).

5.2 PCP Referral Authorizations (DE Only)

Under Highmark’s Independent Practice Association (IPA) and Point of Service (POS) plans in Delaware, members are required to select a PCP who will work with them to coordinate their health care needs.

When the PCP or treating specialist determines that a referral to another provider is medically necessary, he or she initiates the referral authorization process. Referrals should be made only to network participating providers.

Process

Requests for referral authorizations must be submitted to Highmark’s Medical Clinical Services department.

• Telephone: 1-800-572-2872
• Fax: 1-800-670-4862

When Highmark authorizes a referral to a network provider, the medical management staff will enter the authorization into Highmark’s system. Payment for claims received for services requiring a referral authorization will be denied without the required authorization.

Non-Network Referral Authorization

In rare, extenuating circumstances, if a referral must be made to a non-network provider, Highmark may grant authorizations.

• PCPs or referral specialists generally initiate non-network referral authorizations.
• These requests usually involve special or unique circumstances where the most appropriate course of action may be to authorize patient care from a non-network provider.

If a member with a plan requiring referral authorization sees a non-network provider without a non-network referral authorization, Highmark will deny payment for services.

To obtain a non-network authorization, the provider must call Highmark’s Clinical Services department and provide the following information:

• The details concerning the patient and his or her condition;
• The non-network provider’s name, address, phone number, and specialty; and
• The reasons why a network provider is not adequate.

The Highmark Medical Director will review the request and notify the requesting provider as soon as the review is completed.

Additional Services

If the referral provider determines that additional services are required, the following guidelines apply:

• If the original authorization from the referring PCP was for consultation only, the referral provider must request additional services from the PCP or contact Highmark’s Clinical Services department directly.
• If the original authorization from the referring PCP was for consultation and treatment, the referral provider is approved to render limited services without requiring additional authorization from the PCP. Any changes or additional requests for services require authorization by Highmark. The referral provider must contact Highmark’s Clinical Services department directly to request the authorization. Examples of such services include:
  • Surgery, diagnostic testing, or other treatment for the same condition as the original referral.
  • Treatment, such as physical therapy, that is for the same condition as the original referral.
  • Referral to another specialist for the same or related condition.

If the original authorization from the referring PCP was for consultation and treatment, the referral provider is not approved to render the following services without going back to the PCP for additional authorization:

• Surgery, diagnostic testing, or other treatments that is not for the same condition as the original referral.
• Referral provider identifies new or different condition requiring consultation by another specialist.

5.2 Prior Authorizations for Non-Participating Providers (PA-FPH)

There may be occasions when an HMO member in the 13-county Northeastern Region in Pennsylvania requires services that cannot be provided by a specialist or facility within the First Priority Health (FPH) network. If services are not available through a FPH network participating provider, prior authorization must be obtained for any services provided by a non-participating specialist or facility.

General Information

The following guidelines apply to non-participating provider prior authorizations for services not available from a FPH network participating specialist or facility:

• If a member receives care without a prior authorization from his/her referring participating provider and approval from Highmark, the member may be responsible for payment for all services rendered.
• All prior authorizations for services by non-participating providers should be issued prior to the member receiving the services.
• Covering PCPs may request prior authorizations for another PCP’s patient(s).
• Prior authorizations are not a guarantee of payment by Highmark. The non-participating prior authorization is void for services that are not medically necessary or not covered.
• Non-participating provider prior authorization guidelines apply to all products using the FPH network (i.e., fully insured, Plus, self-funded, CHIP).
• Prior authorizations for elective services by non-participating providers are required at least two (2) weeks prior to the member’s target service date.

Requesting Prior Authorization

Prior authorization for all non-participating outpatient physician and/or outpatient facility services may be requested by completing the Outpatient Non- Participating Provider Request Form and faxing it to the fax number for migrated business for Highmark indicated on the form. This form is also available on the Highmark Blue Shield Provider Resource Center — select Education/Manuals, and then click on First Priority Health Network Resources.

Prior authorization/precertification can also be requested for non-participating provider services by contacting the Clinical Services Department by calling the Provider Service Center phone line for your service area.

5.2 New York Regulations (NY Only)

Out of Plan Referral Process

Out-of-plan (OOP) referrals for urgent care are made to providers or facilities not participating with Highmark Blue Cross Blue Shield of Western New York or Highmark Blue Shield of Northeastern New York when:

• the member is outside the Highmark Blue Cross Blue Shield of Western New York/Highmark Blue Shield of Northeastern service area
• participating providers in the area cannot provide the necessary services

OOP referrals are made by the PCP or specialist and require review by the Utilization Management Department. If you believe that the service is materially different then what is available in-network, we require:

1. A written statement from the enrollee's attending physician, who must be a board certified or board eligible physician qualified to practice in the specialty area of practice appropriate to treat the enrollee for the health service requested, that the requested out-of-network health service is materially different from the health service the health care plan approved to treat the insured's health care needs; and
2. two documents from the available medical and scientific evidence that the out-of-network health service is likely to be more clinically beneficial to the enrollee than the alternate recommended in-network health service and for which the adverse risk of the requested health service would likely not be substantially increased over the in-network health service.

If you believe that there is not an appropriate in-network doctor who can provide the service needed, we require a written statement from you explaining:

1. Why in-network doctors do not have the appropriate training and experience to meet particular needs; and
2. Why you recommend an out-of-network doctor who has the appropriate training and experience and is able to provide the service.

You must be licensed and board certified or board eligible, and qualified to practice in the specialty area appropriate for the treatment needed.

The member's care should be directed to an in-network provider as soon as his or her condition(s) permits it.

Out-of-Plan referrals cannot be backdated.

Examples of Out-of-Plan Coverage

OOP referrals are not made for patient convenience. The following circumstances must apply:

1. The covered service is not available from a participating in-network provider
2. A specialty provider is not available in-plan
3. Possible access issues

If the services are deemed necessary and are a covered service to a member in-network, the plan will adequately and timely cover these services for as long as the plan is unable to provide the service in-network.

Second opinions will also be arranged for a member should an appropriate professional not be available in-network. This will occur at no more cost to the member than if the service was obtained in-network.

Travel Time and Distance Standards:

• 30 minutes or 30 miles for PCPs.
• For all other providers, it is preferred that they satisfy the 30-minute or 30-mile standard (not required).

This does not apply for patient convenience.

The above 30 miles/30 minutes travel time rule does not apply to a specialty M.D.

Speciality Care Coordinators

Certain medical conditions require a specialist or specialty-care center to provide and/or coordinate the member's primary and specialty care. In these cases, a specialty care coordinator (SCC) may be designated. The Medical Director must approve the designation of SCC.

The SCC does not require a referral from the primary care physician (PCP) and may authorize referrals, procedures, and other medical services to the same extent the primary care provider would be able.

Such referral shall be made pursuant to a treatment plan developed by a specialty care center and approved by the HMO, in consultation with the primary care provider, if any, or specialist. Among other things, the treatment plan may set time limits on the SCC's authority or may establish the scope of services that may be provided or authorized by the SCC. 

To be eligible for care by a Specialty Care Center, the member must be afflicted with the following, which will require specialized medical care over a prolonged period of time:

• A life-threatening condition or disease, or;
• A degenerative and disabling condition or disease.

Diagnoses that may be classified as degenerative and disabling conditions may include but are not limited to:

• Cancer
• Cerebral Palsy
• Conditions necessitating an organ transplant
• Cystic fibrosis
• Hemophilia
• HIV/AIDS
• Multiple Sclerosis
• Sickle Cell Anemia

A Specialist Care Coordinator may be requested by:

• the member (upon enrollment)
• the member's current PCP
• the member's specialist

A Specialist Care Coordinator who is not a participating provider will only be approved if the Medical Director determines that we do not have a provider in the network with the appropriate training and expertise to provide the care necessary, and that a Specialist Care Coordinator is required and appropriate.

Members receiving care by a Medical Director-approved Specialty Care Center that is a non-participating provider, cannot be required to pay any more out-of- pocket expense than they would have when treated by a participating provider.

Summary of Specialty Care Coordination Process

1. Request for Specialist Care Coordinator (SCC).
2. Utilization Management (UM) reviews patient history and discusses request with patient, PCP, specialist, and Medical Director.
3. Decision is rendered with one of the following options:
   1. Maintain PCP, but allow one year referral to specialist
   2. Request new PCP with appropriate sub-specialty
   3. Request SCC for patient
4. Letter sent to member, provider, and specialist with decision determination.

Speciality Care Centers

A Specialty Care Center is a center accredited or designated by an agency of the state or federal government or by a voluntary national health organization as having special expertise in treating the disease or condition for which it has been accredited or designated. If we determine that our provider network does not have a Specialty Care Center with the appropriate expertise to treat a member's disease or condition, the member's PCP may request a referral to a non- participating provider. To request a referral, the PCP may contact our Utilization Management Department at 1-844-946-6263.

Summary of Specialty Care Coordination Process

1. Request for Specialist Care Coordinator.
2. Utilization Management (UM) reviews patient history and discusses request with patient, PCP, specialist, and Medical Director.
3. Decision is rendered with one of the following options:
   1. Maintain PCP, but allow one year referral to specialist
   2. Request new PCP with appropriate sub-specialty
   3. Request SCC for patient
4. Letter sent to member, provider, and specialist with decision determination.

If we determine that a member's disease is life-threatening, or degenerative and disabling, and will require specialized medical care over a prolonged period of time, we will authorize an in-network referral to a Specialty Care Center that has the expertise to treat the member's disease or condition.

5.2 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.