Legislation Impacts Highmark Blue Cross Blue Shield West Virginia in 2020

In February of 2019, the West Virginia legislature passed West Virginia House Bill 2351, which impacts the prior authorization process for healthcare providers rendering services for certain West Virginia insureds.

In compliance with this legislation, beginning January 1, 2020 Highmark has:

  • Implemented five (5) episodes of care for prior authorization.
  • Developed an exception based utilization management program ‘Gold Carding’ for providers who meet the 100% approval rating mandated by the legislation for procedures subject to prior authorization.
  • Enhanced the Transition of Care of Prior Authorization policy to facilitate transfers of prior authorizations for members coming from a previous insurance carrier.
  • Updated the Pharmacy IP Prescription process to allow up to 10 days of certain prescription medications upon discharge from an inpatient stay without requiring prior authorization.

Prior Authorization Episodes of Care

A Prior Authorization Episode of Care is a grouping of outpatient services requiring prior authorization that generally follow a pre-identified trigger code. By requesting a Prior Authorization Episode of Care, outpatient services which would typically require separate authorization requests will be included (approved) if the initial trigger procedure is approved.

Be aware that the provider must know the performing provider information for each service within the prior authorization episode of care at the time the request is made. Authorization review for benefit eligibility and criteria for medical necessity and appropriateness will be done on the outpatient trigger code identified for each episode.

The outpatient Prior Authorization Episodes of Care include:

  • Hip Replacement
  • Knee Replacement
  • Knee Arthroscopy
  • Lumbar Laminectomy
  • Shoulder Replacement

To request an outpatient prior authorization episode of care, please call the Utilization Management MSK Dedicated Team at 1-800-452-8507 and select option 4.

 

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