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

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

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 Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for prior authorization.

Definitions

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) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Procedures

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

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

All requests for covered services requiring prior authorization must be submitted to Highmark Health Options for medical necessity determination. Nationally accredited, evidence-based, medically appropriate criteria, such as InterQual, or other medical-appropriateness criteria approved by BMS, are utilized for reviewing medical necessity of services requested.

It is the responsibility of the enrolled treating, prescribing, ordering, or referring practitioner to submit a request to HHO with relevant medical documentation that justifies the medical necessity of the proposed procedure/service. Clinical documentation submitted for prior authorization review must not be more than six months old.

If the covered services are provided before the prior authorization is confirmed, the service will be denied and cannot be reimbursed by HHO. Request for or receipt of prior authorization does not guarantee approval or payment.