DISCLAIMER

Highmark Health Options 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 medical benefits, 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 West Virginia Department of Human Services (DHS) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for Out of Network Services.

Definitions

Border Provider- Healthcare facilities within thirty ( 30 ) miles of West Virginia’s state lines and accept West Virginia Medicaid reimbursement

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT).

In-Network Provider: West Virginia Medicaid enrolled provider that is physically located within thestate, or within the 30-aeronautical mile radius of its border. This includes select specialty hospitals located out of the state and their affiliated practitioners and providers located beyond the 30-mile radius that have special agreements with WV Medicaid, such as sole source providers.

Out-of-Network Provider: Any provider located outside of the state of West Virginia, beyond the 30-aeronautical mile radius of the West Virginia border that has been approved for enrollment with WV Medicaid. These providers can provide covered WV Medicaid services. However, prior to rendering any service they must obtain prior authorization, except in medically necessary emergent situations as defined in WV State Code §33-1-21, or in cases where a foster child has been placed out-of-state and/or resides in an out-of-state Psychiatric Residential Treatment Facility (PRTF). Out-of-Network provider contracts require that all non-emergent services, per BMS policy, are only approved when an In-Network provider is not available or appropriate to treat the member

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

This policy is designed to provide direction on HHO’s (The Plan) reimbursement for out-of-network (OON) services. OON reimbursement applies to claims where the submitting provider has not entered into a contractual arrangement with The Plan or appropriate Blue Cross Blue Shield (BCBS) licensee (within the service area where services are delivered) requiring the provider to accept the allowable reimbursement as

"payment in full.” Reimbursement for OON services uses standard reimbursement methodologies to ensure adequate provider reimbursement is maintained for emergent and non-emergent services delivered by both In-Area OON and Out-of-Area (OOA) OON providers. HHO is fully compliant with all federal (e.g. No Surprises Act (NSA)). and all state laws regarding surprise billing prohibitions.

Billing and Reimbursement:

OON reimbursement is applicable to any claim where the submitting provider is not contracted with The Plan or appropriate BCBS licensee (e.g. non-participating). Highmark reserves the right to price claim up to provider charges to comply with comply with State Law.

WV Out of-Network Reimbursement

This policy ensures emergency services provided out-of-network are reimbursed equal to the Medicaid or WVCHIP prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate.

Highmark will pay an enrollee’s existing out-of-network hospital fees for medically necessary covered emergency services until the enrollee’s records, clinical information and care can be transferred to a network hospital, or until such time as the enrollee is no longer enrolled in that MCO, whichever is shorter.

Non-emergent services are reimbursed at the 80% of participating providers’ rates. All out-of-state providers’ claims for providing non-emergency medical services will deny unless:

1. The provider is enrolled as a “border” provider

2. The provider is enrolled as an “in-state” provider

3. The services have been prior authorized.

ADDITIONAL BILLING INFORMATION AND GUIDELINES:

Billing requirements are specific, follow established industry standards, and are strictly enforced. Failure to adhere to the required standards may result in claim denial until requirements are met. Reimbursement may be dependent upon medical policy, reimbursement policy, or other administrative policies depending on the specific situation and location of service delivery.

This is a standard reimbursement policy and other contractual agreements directing other reimbursement methods for OON claims may supersede this policy, as applicable.

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement.

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract.