Chapter 4 Health Care Management Unit 2: Introduction to s In This Unit Topic See Page Unit 2: Introduction To s Introduction To s 2 Remember: Highmark has eliminated referral requirements; however, authorization requirements continue to exist. Note: The processes discussed in this unit do not pertain to pharmaceutical authorizations or prior authorizations for certain outpatient, advanced imaging services under the Radiology Management Program. For more information about pharmacy policies please visit the Pharmacy/Formulary Information section of the Provider Resource Center. Certain outpatient and advanced imaging services need to be authorized. For more information about the Radiology Management Program, please visit the Radiology Management Program section of the Provider Resource Center. 1
4.2 Introduction to s Definition (preauthorization) is the process whereby the health care practitioner must contact Highmark to determine the benefit coverage for and/or the medical necessity or appropriateness of health care services. Overview Throughout the year, Highmark Blue Shield adds and/or deletes procedures/dme that require authorizations under the commercial HMO and POS products, as well as Medicare Advantage, and communicates these changes to the provider community. To view the all-inclusive and most up-to-date list, please visit the Provider Resource Center and select, Procedures Requiring under Administrative Reference Materials. Products Requiring The following products require authorizations: Medicare Advantage PPO, DirectBlue* Medicare Advantage PPOBlue* HMO EPOBlue* DirectBlue (group) *Has limited authorization requirements: generally, ClassicBlue only for inpatient care depending on the benefit Western Region HMO design. ShortTermBlue What Region Am I? Responsibility For Requesting can be requested by the following parties: A member s PCP A member s Specialist The facility to which the member has been admitted 2
4.2 Introduction to s, Continued When An Is Required The following circumstances are representative of those that require an authorization. This is not an all-inclusive list. A list of procedures and DME that require authorization can be found on the Provider Resource Center by hovering over Administrative Reference Materials and clicking Procedures Requiring. All hospital admissions Cosmetic vs. reconstructive procedures Non-standard issue DME Experimental/investigational procedures or treatments Nutritional Counseling Selected injectable drugs Home health care Diabetic education Out-of-network care Alternative medicine Home Health Oxygen (For All Medicare Advantage Members) All Therapies (For Medicare Advantage HMO and Medicare Advantage PPO out-of network) NOTE: The authorization requirement associated with spinal manipulation for Medicare Advantage members was eliminated as of June 1, 2005. NaviNet Benefit Verification For NaviNet users: Step Action 1 Click on Eligibility and Benefits Inquiry 2 Enter the Member Information 3 Click Select beside the correct patient name 4 The Patient Eligibility and Benefits Detail Screen will appear. This screen displays current benefits for the member. 3
4.2 Introduction to s, Continued NaviNet Benefit Verification (continued) Step Action 5 Review member benefits within the categories. Phone Benefit Verification Certain procedures require benefit verification prior to performing the procedure. NaviNet is the required method for benefit verification. What Region Am I? However, if you are not a NaviNet enabled provider, please call the appropriate number below for benefit verification: Western Region: 1-800-547-3627, Option 2 Central Region: 1-866-731-8080, Option 2, then Option 2 For Medicare Advantage Members call 1-866-517-8585. If you have specific questions about authorization or benefit verification please contact your Provider Relations Representative. 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 s having coverage at the time the service is rendered and the type of coverage available under the member s benefit plan. Some benefit plans may also impose deductibles, coinsurance, co-payments and/or maximums that may impact the payment. Providers may consult NaviNet, InfoFax, or OASIS or to obtain benefit information. Failure To Obtain And Failure to pre-authorize or pre-certify a service or admission may result in a retrospective review. Highmark Blue Shield 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 HMS determines that the service was medically necessary and appropriate, the claim will be paid. 4
4.2 Introduction to s, Continued Failure To Obtain And (continued) HMS 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). If The Member Still Wants A Service For Which Can Not Be Obtained If an authorization has not been obtained because it has been determined that the care is either not medically necessary/appropriate or a non-covered service, the member may still want to receive the service. In such cases, the provider can have the member acknowledge the financial responsibility, in writing, for the specific service to be received. If The Is Not In Place At The Time Of Service Ordinarily, the member s attending physician should have requested any required authorization prior to the member receiving the services. However, if a Highmark Blue Shield member presents him or herself for non-emergency services and the required authorization does not appear to be in place, the provider has the following options: Perform an authorization inquiry in NaviNet Contact HMS directly to request an authorization at 1-866-731-8080 between the hours of 8:30 a.m. and 7:00 p.m. Monday through Friday. For urgent care, HMS is also available between the hours of 8:30 a.m. and 4:30 p.m. on Saturday and Sunday. For Behavioral Health Management authorization requests, call 1-800-628-0816. 5