General Medical/Surgical
Nationally recognized evidence-based criteria and corporate medical policies that consider regional and local variations in medical practiced member needs are used to determine the medical necessity and clinical appropriateness of utilization decisions. The InterQual criteria are embedded into the care management system and are available to all medical and behavioral health clinicians. All medical policies can be accessed on-line by providers as well as staff. The Utilization Management staff use the following criteria, guidelines and policies:
Behavioral Health
Nationally recognized evidence-based criteria and corporate medical policies that consider regional and local variations in medical practice and member needs are used to determine the medical necessity and clinical appropriateness of utilization decisions. The InterQual criteria are embedded into the care management system and are available to all medical and behavioral health clinicians. All medical policies can be accessed on-line by providers as well staff.
The Behavioral Health Utilization Management staff use the following criteria and guidelines:
Highmark Health Options Financial Investigations and Provider Review (FIPR) department's mission is to support Highmark Health Options vision of providing affordable, quality health care by ensuring that provider reimbursements are appropriate and to protect Highmark Health Options’ assets by investigating and resolving suspected incidents of health care insurance fraud, waste, or abuse.
In addition to conducting post-payment practice pattern reviews, FIPR also investigates potential member and provider fraud and abuse. Health insurance fraud occurs when a provider or consumer intentionally submits, or causes someone else to submit, false or misleading information to a health insurance company for the intention of changing the amount of health care benefits paid. Highmark Health Options’
FIPR unit takes a proactive approach to detecting and investigating potential health care fraud and abuse. When necessary, FIPR takes internal and/or external corrective action regarding fraudulent activity that impacts Highmark Health Options, its customers, or members.
The Fraud, Waste and Abuse processes that investigate and identify fraud though pre-payment and post-payment reviews are non-quantitative limits that may impact the scope or duration of treatment by affecting the payment of benefits to a provider or member. This limitation may occur through the denial of claims (pre-payment review) and recovery of overpaid claims (post-payment review).
Pre-payment review may be applied to the claims or a provider or member for whom there is a basis to suggest irregular or inappropriate services based on the claims submitted, referral tips from the fraud hotline or other means. A pre-payment review entails review of each claim, requests for additional information to support and/or validate the claim and, if necessary, may result in denial of the claim if not substantiated. This process may be applied to any provider or member’s claims without regard to the payer, the amount of claim, type of service etc.
Post-payment review is conducted when an algorithm, routine claims audit, referral tips from the fraud hotline or other information suggests the need for review of a provider’s billing practices and patterns after claims have previously been processed and paid. A post-payment review will involve an audit for a period that will not exceed one year under current policy and uses a sampling and extrapolation methodology. For mental health and substance use disorder claims however, audits are limited to cases where the amount of claims exceeds a $10,000 threshold as a specified minimum amount involved or potential probable recovery. The audit and investigation will involve review of contemporaneous treatment records as well as member and provider interviews.
Yes, an experimental or investigational procedure is generally defined as the use of a service, supply, drug or device that is not recognized as standard medical care for the condition, disease, illness or injury being treated as determined by the health plan based on independent review of peer reviewed literature and scientific data. Investigational and experimental (I&E) tests have insufficient data to determine the net health impact, which typically means there is insufficient data to support that a test accurately assesses the outcome of interest analytical and clinical validity), significantly improves health outcomes (clinical utility), and/or performs better than an existing standard of care medical management option. Such tests are also not generally accepted as standard of care in the evaluation or management of a particular condition.
The Medical Policy Department develops and maintains Highmark Health Options’ clinical policies. These policiesaddress clinical coverage criteria, including medical necessity and investigational/experimental issues. There is an established process forthe evaluation of new technology and new applications of existing technology, including those for medical procedures, behavioral health procedures, and devices. The Medical Policy Department prepares in depth summaries on topics under evaluation. These summaries include, but are not limited to, the following information:
In selecting and credentialing providers for the associate networks, Highmark Health Options does not discriminate in terms of participation or reimbursement against any health care professional who is acting within the scope of their license or certification. In addition, Highmark Health Options does not discriminate against professionals who serve high-risk populations or who specialize in the treatment of costly conditions. If Highmark Health Options declines to include a provider in its networks, Highmark Health Options will furnish written notice of the reason for its decision to the affected provider.
In Network
Providers are initially credentialed prior to network admission and recredentialed at least every three years. Highmark conducts verification of the practitioners as defined by their policies, State, and Federal regulations, and in accordance with accrediting standards.
The following is a general summary of Highmark Health Options’ credentialing criteria for all practitioners.
Reimbursement will be based on the current plan allowance in place at the time services were rendered.
The Pharmacy Benefit does not place exclusions for 'failure to complete a course of treatment.'
Fail first requirements are required for certain medical and pharmacy medications. Typically, step therapy requirements are imposed only if the drug that members are required to “step through” has similar or improved efficacy or safety over the alternative targeted drug. The implementation of step therapy requirements also considers provider prescribing preferences and the cost of the alternative targeted medications.
Step Therapy requirements are applied only when multiple other generic or brand formulations within the same medication category are available. The drugs targeted by step therapy are from a wide breath of therapeutic categories. The Medical and Pharmacy departments apply objective criteria outlined in documented medical and pharmacy policies.
Highmark Health Options Pharmacy maintains compliance with the Delaware Division of Medicaid and Medical Assistance (DMMA) Preferred Drug List (PDL) and manages other drugs from classes not addressed in the DMMA PDL as a Supplemental Formulary, collectively known as the Formulary. A process is in place to ensure that Highmark Health Options sends required notifications to members and prescribing practitioners related to changes in the Formulary.
The formulary status for each individual drug within a class is determined based of its efficacy, safety, patient acceptance, unique clinical characteristics, and local physician experience and input. Drugs must meet the following requirements before being reviewed and considered for a formulary:
An operational policy describing the formulary development and maintenance is reviewed and approved at least annually by a review committee. A pharmacy policy with clinical criteria to allow exceptions for members with a closed formulary to have get access to a non-formulary medication is reviewed annually by the Pharmacy & Therapeutics Committee.
Yes, there are certain Highmark Health Option products that require non-emergency services to be authorized as a condition of coverage.
Providers are required to contact Utilization Management to obtain authorization for in-network inpatient admissions.
Members are required to contact Utilization Management to obtain authorization prior to in-network inpatient admissions outside of the Highmark Health Options service areas.
Yes, concurrent review, also known as continued stay review, is the process for assessing and determining the ongoing medical necessity and appropriateness for an extension of services that have been previously authorized.
Concurrent review is available to all services subject to prior authorization.
Retrospective Review (also known as post-service) is the process of assessing the appropriateness of medical services rendered to a member after the service has been provided.
The Medical Review staff review the medical record documentation for medical necessity and appropriateness using established criteria. The review may be conducted for all or part of the treatment/service. The determination is based solely on the medical information available to the attending physician or ordering provider at the time that the medical care was provided. During this process, Care Managers will also identify opportunities for referrals to case management or condition management programs. Physicians are often consulted to review high dollar equipment or services, cosmetic and experimental services or to review potential quality of care concerns.
All Highmark Health Options products require that certain services be authorized as a condition of coverage. However, benefits can vary; always confirm authorization requirements under the member’s coverage prior to providing services.
Outpatient requests should be made at least twenty-four (24) hours prior to the expiration of the original authorization period (last day of treatment).
In Network and Out of Network
Retrospective review (also known as post-service review) is the process of assessing the appropriateness of medical services rendered to a member after the service has been provided.
Retrospective review is available for all services subject to prior authorization and concurrent review.
