HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Z-38-007
Topic:
Hospital Admission Provision (Benefits After Contract Termination)
Section:
Miscellaneous
Effective Date:
December 4, 2017
Issued Date:
February 11, 2019
Last Revision Date:
January 2019
Annual Review:
January 2019
 
 

The hospital admission provision specifies financial payment responsibility of covered services when a subscriber is an inpatient of a hospital, skilled nursing facility (SNF), or rehabilitation facility on the day that coverage terminates.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Benefits should not be provided for services incurred prior to the subscriber's contract effective date, or during an inpatient admission that commenced prior to the contract effective date.

However, if the subscriber is an inpatient of a hospital, skilled nursing facility (SNF), or rehabilitation facility on the day that coverage terminates, benefits may be provided until the maximum amount of benefits has been paid, or until the inpatient stay ends, whichever occurs first.

The above provision does not apply to services rendered in a second facility if the patient is transferred from one type of facility to another (e.g., hospital to SNF, etc.). However, payment should be considered for services provided in a second facility when the patient is transferred from hospital to hospital when the first hospital is unable to treat the patient's condition(s). In this circumstance, admission to the second hospital is considered a continuation of the first admission. Transfers made at the patient's request for personal convenience are not covered under the hospital admission provision.

Coverage for hospital admission provisions is determined according to individual or group customer benefits.


Place of Service: Inpatient



The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.