Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options Duals services for Inpatient Only.
Definitions
Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.
Prior Authorization
Prior authorization is required.
Procedures
Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Local Coverage Article (LCA) information, as well as other CMS sources.
Post-payment Audit Statement
The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.
HHO Duals follows the guidance regarding procedures, identified by Medicare, as ‘Inpatient-only’ and will reimburse inpatient-only procedures regardless of the anticipated length of stay.
References
Novitas Solutions, Inc. Part B Fact Sheet: Observation Services. Last modified March 20, 2019. Accessed August 2, 2022.
Centers for Medicare and Medicaid Services (CMS). Local Coverage Article (LCA) Billing and Coding: Acute Care: Inpatient, Observation and Treatment Room Services (A52985). Original Effective date October 1, 2015. Revision Effective date January 1, 2022. Accessed on August 2, 2022.
Medicare Claims Process Manual: Chapter 30-Financial Liability Protections. Published date January 21, 2022. Accessed on August 2, 2022.
Centers for Medicare and Medicaid Services (CMS). Newsroom Fact Sheet: Two-Midnight Rule. October 30, 2015. Accessed on August 2, 2022.
Centers for Medicare and Medicaid Services (CMS). Hospital Outpatient PPS. CY 2022 Inpatient only (IPO) list. Addendum E. – Final HCPCS Codes that Would Be Paid Only as Inpatient Procedures for 2023. Accessed on July 12, 2023.
Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual, Chapter 4 – Part B Hospital. Revision date June 15, 2022. Accessed on August 2, 2022.
Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual, Chapter 6 – Hospital Services Covered Under Part B. Revision date December 31, 2020. Accessed on August 2, 2022.
Contact Us
For questions related to this policy, contact the Highmark Government Market Policy Team at GovernmentPolicy@Highmark.com
