Provider Guide to FreedomBlue
In this manual This manual contains information on the topics listed below:
Topic
FreedomBlue: A Medicare Advantage PPO from Highmark
Blue Shield in Association with Blue Cross of Northeastern
Pennsylvania
The Rights of FreedomBlue Members
The Responsibilities of FreedomBlue Members
Characteristics of PPO Programs
Medical Management Requirements: Authorization of
Inpatient Admissions
Medical Management Requirements: Transfers
Medical Management Requirements: No Authorization
Required for Emergency Services
Medical Management Requirements: Outpatient Services
Medical Management Requirements: Outpatient Therapies
Medical Management Requirements for Medical Services:
Mechanics of the Authorization Process
Medical Management Requirements: Outpatient Mental
Health and Substance Abuse Treatment Services
Authorization, Benefits and Reimbursement
Facility Denials
Requesting a Retrospective Review
Processes Specific to Medicare Advantage Members: Pre-
Service Denials
Processes Specific to Medicare Advantage Members: Notice of Discharge and Medicare Appeal Rights (NODMAR) for
Hospitals
Processes Specific to Medicare Advantage Members: Notice of Medicare Non-Coverage (Skilled Nursing Facility)
Processes Specific to Medicare Advantage Members: Notice of Medicare Non-Coverage (Home Health Agency)
Facility Appeal Process: FreedomBlue
Submitting a Standard Appeal of an Initial Adverse Medical
Necessity Decision: Concurrent Denial
Submitting a Standard Appeal of an Initial Adverse Medical
Necessity Decision: Retrospective Denial
Facility Filing an Appeal on Behalf of a FreedomBlue
Member
See Page
3
6
8
9
10
12
13
14
15
17
18
19
20
21
22
23
25
29
33
34
35
36
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Provider Guide to FreedomBlue
Continued
In this manual (continued)
Topic
Appealing a Pre-Service or Concurrent Denial on Behalf of a
FreedomBlue Member
Appealing a Post-Service Denial on Behalf of a FreedomBlue
Member
Important Telephone Numbers
See Page
38
40
41
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Provider Guide to FreedomBlue
FreedomBlue:
A Medicare
Advantage PPO from Highmark
Blue Shield in
Association with Blue Cross of Northeastern
Pennsylvania
FreedomBlue is a Medicare Advantage Preferred Provider Organization
(PPO) product from Highmark Blue Shield in association with Blue Cross of
Northeastern Pennsylvania. It offers Medicare-eligible individuals the convenience of a PPO arrangement, through which covered health care services are reimbursed at the highest level when members receive these services from network providers. Most services performed by non-network providers are also covered, with a higher level of member cost-sharing.
FreedomBlue is administered by Highmark Blue Shield in association with
Blue Cross of Northeastern Pennsylvania, in accordance with regulations of the Centers for Medicare and Medicaid Services (CMS).
“Medicare
Advantage” programs
Medicare participation
In an effort to make broader and more cost-effective coverage options available to people eligible for Medicare, the Health Care Financing
Administration (HCFA, now known as the Centers for Medicare and
Medicaid Services) created “Medicare Part C.”
This term includes a wide variety of delivery models – including Preferred
Provider Organizations -- which serve as replacements for Original Medicare.
All of these models are funded through a combination of payments from the
Medicare program and the member’s premium.
Such plans were originally known as “Medicare+Choice” plans but now are called “Medicare Advantage” programs.
To be included in a Medicare Advantage provider network, a provider must participate in the Medicare program itself.
At least the benefits provided under
Original
Medicare
At a minimum, Medicare Advantage programs such as FreedomBlue are required to provide coverage for the services covered by Original Medicare.
They may also provide additional services and benefits.
FreedomBlue offers its members additional benefits and services beyond those covered by the Medicare program. These include preventive services, routine dental and vision care and prescription drugs (including a Medicareapproved prescription drug discount card).
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Provider Guide to FreedomBlue
Continued
Latitude in delivering covered benefits
Support services
Please note that while Medicare Advantage plans are required to provide at least the same benefits offered to members with Original Medicare coverage, they have latitude in the way those covered benefits are applied. Medicare
Advantage plans can, for example, apply medical management requirements and define the network within which services can be rendered.
Medical policy To the extent that it is available, Medicare Advantage medical policy applies to all services provided to members with coverage under FreedomBlue. If no
Medicare Advantage medical policy exists on a particular topic, Highmark
Blue Shield medical policy applies.
Like Highmark Blue Shield’s own medical policy information, Medicare
Advantage Medical Policy is available via the Blue Cross of Northeastern
Pennsylvania-hosted NaviNet portal or Secure Access or the Highmark Blue
Shield-hosted Navinet System.
FreedomBlue Members also have access to support services such as the following:
 SilverSneakers® Fitness Program membership to encourage health and well-being through exercise

Computer-delivered lifestyle improvement programs on topics such as weight management, nutrition, smoking cessation and stress management

Dr. Dean Ornish Program for Reversing Heart Disease, available to all medically qualified members

Highmark Osteoporosis Prevention and Education (HOPE), for members diagnosed with or at risk for developing osteoporosis

Blues On Call
SM
Health Information and Decision Support Line, a toll-free service which supports members’ relationship with their physicians by providing information to support well-informed questions and decision-making
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Provider Guide to FreedomBlue
Continued
CMS regulation Because Medicare Advantage programs are funded partly by the Medicare
Program itself, it also regulates many administrative aspects of the program, including processes intended to safeguard members’ rights.
For more information about these processes, please see pages 6 and 7.
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Provider Guide to FreedomBlue
Members’ rights
FreedomBlue members have the right to…
1.
Be assured that they will not be discriminated against in the delivery of health care services consistent with the benefits of their plan, based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment.
2.
Receive considerate and courteous care, with respect for personal privacy and dignity.
3.
Select their own preferred provider or physician group from the
Highmark Blue Shield Medicare Advantage PPO Network.
4.
Expect their provider’s team of health care workers to provide or to help them arrange for all the care that they need
5.
Participate in the health care process. If they are unable to fully participate in this discussion, they have the right to name a representative to act on their behalf.
6.
Receive enough information to help them make a thoughtful decision before they receive any recommended treatment.
7.
Be informed of their diagnosis and treatment plans in terms they understand and participate in decisions involving their medical care.
8.
Talk openly with their network provider about appropriate and medically necessary treatment options for their condition, regardless of cost or benefit coverage.
9.
Have reasonable access to appropriate medical services.
10.
Be provided with complete information about FreedomBlue, including the services it provides, the practitioners who provide care and information on member rights and responsibilities.
11.
Confidential health records, except when disclosure is required by law or permitted in writing by you with adequate notice. They have the right to review their medical records with their participating network doctor.
12.
Express a complaint and receive an answer to their complaint within a reasonable period of time.
13.
Appeal a decision by FreedomBlue if they feel they have been denied a covered service. They may make this appeal directly to
FreedomBlue or through a Social Security office or Railroad
Retirement Board office (if they are an annuitant).
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Provider Guide to FreedomBlue
Continued
Members’ rights, continued
14.
Immediate Quality Improvement Organization review of decisions for hospital discharges, as explained in the Centers for Medicare and
Medicaid Services’ “Important Message,” which is given to Medicare members at the time of admission to a hospital, and in the Notice of
Discharge and Medicare Appeal Rights given prior to discharge if the member disagrees.
15.
Call Member Service, Monday through Friday, between 8:00 a.m. and
4:30 p.m. at 1-866-306-1061 (TTY users, please call 1-800-988-0668), to request the following information about Highmark Blue
Shield/FreedomBlue:
- How FreedomBlue controls the use of medical services
- The number of appeals and grievances FreedomBlue has received and how these cases were resolved
- How FreedomBlue pays its participating doctors
- The financial condition of the plan
16.
Make suggestions about FreedomBlue’s policies on member rights and responsibilities.
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Provider Guide to FreedomBlue
Members’ responsibilities
FreedomBlue members have the responsibility to…
1.
Read all FreedomBlue materials carefully and immediately upon enrollment and ask questions when necessary. They have the responsibility to follow the rules of FreedomBlue membership.
2.
Identify themselves as a FreedomBlue member when scheduling appointments, seeking consultations with their physician and upon entering any Highmark Blue Shield/Blue Cross of Northeastern
Pennsylvania Medicare Advantage PPO Network provider’s office.
3.
Treat all Highmark Medicare Advantage PPO Network physicians and personnel respectfully and courteously as their partners in good health care.
4.
Communicate openly with the physician they choose. They have the responsibility to develop a physician-patient relationship based on trust and cooperation.
5.
Keep scheduled appointments or give adequate notice of delay or cancellation.
6.
Ask questions and make certain that they understand the explanations and instructions they are given.
7.
Consider the potential consequences if they refuse to comply with treatment plans or recommendations.
8.
Pay any applicable physician office, emergency room and prescription drug copayments at the time of service.
9.
Pay any applicable FreedomBlue premiums on time.
10.
Pay their Medicare Part B premiums (and Part A, if applicable).
11.
Help maintain their health and prevent illness and injury.
12.
Help FreedomBlue maintain accurate and current medical records by being honest and complete when providing information to health care professionals.
13.
Express their opinions, concerns or complaints in a constructive manner to the appropriate people at FreedomBlue.
14.
Notify the FreedomBlue Member Service Department, Monday through
Friday, between 8:00 a.m. and 4:30 p.m., at 1-866-306-1061 of any changes in their personal situation which may affect the plan’s ability to communicate with them or provide health care to them, including any changes in their address or phone number, any extended trips or vacations, and of their return to the service area from a trip of up to 6 consecutive months. TTY users, please call 1-800-988-0668.
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Provider Guide to FreedomBlue
Characteristics of PPO programs
FreedomBlue shares the major characteristics of most PPO programs.
The cornerstone of the program is the network:

When members receive covered services from network providers, those services are paid at the higher level defined in the benefit contract. (Some services require a copayment or coinsurance even when rendered by a network provider.)

Members can still receive most covered services from non-network providers, but if they choose to do so, they are responsible for a greater share of the financial responsibility for the services. (In these situations, FreedomBlue reimburses the provider 80% of the Medicare fee schedule for the eligible services after the member has met his or her annual non-network deductible.)
Emergency care, urgent care, renal dialysis
Emergency care, urgently needed care and renal dialysis services are exceptions to the rule described above. These services are covered at the higher network level, regardless of where the care is received. Deductible and coinsurance do not apply to emergency care, urgently needed care and renal dialysis services. (Copayment applies, except for dialysis services; for emergency care, the copayment may be waived if the member is admitted as an inpatient for the emergency condition within three days and the admission is authorized.)
For more information about emergency care, please see page 13.
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Provider Guide to FreedomBlue
Authorization review
Authorization review is the process by which services are evaluated according to criteria for medical necessity and appropriateness – ordinarily before services are rendered, or within 48 hours of the request for an emergency admission.
Purpose of authorization review
The purpose of authorization review is to determine whether the services being requested are medically necessary and appropriate and are being delivered in the most appropriate setting. Authorization review assists Care and Case Managers in identifying potential candidates for post-discharge case management or the Blues On Call SM condition management program.
A provider- driven process
The authorization process is provider-driven for all in-network care. This means that it is the provider’s responsibility to obtain authorization for an inpatient admission or any outpatient services requiring this approval. If authorization is required but not obtained, the corresponding claim will be rejected and the member must be held harmless. In order for the claim to be considered for payment, the provider will need to request a retrospective review and submit the applicable medical records. For more information about requesting retrospective review, please see page 21.
Inpatient admissions require authorization
Authorization is required under FreedomBlue whenever a member is admitted as an inpatient to any of these types of facilities:

Acute-care hospital

Long-term acute-care hospital

Rehabilitation hospital

Mental health or substance abuse treatment facility

Skilled nursing facility
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Provider Guide to FreedomBlue
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Maternity is an exception
Maternity admissions are an exception to the rule above and do not require authorization. Facilities do need to notify Healthcare Management Services that the admission has occurred so that a case record can be established.
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Provider Guide to FreedomBlue
Transfers Transfer of a member from one facility to another requires authorization from
Healthcare Management Services (HMS). The table below identifies which facility has responsibility for obtaining authorization of an inter-facility transfer:
In this situation…
This facility is responsible to contact HMS for authorization
The hospital initiating the transfer A member who has been admitted to one hospital is transferred to another hospital
The receiving hospital A member has been evaluated in the emergency department of one hospital and must be transferred to become an inpatient in another hospital
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Provider Guide to FreedomBlue
No authorization required for emergency services
FreedomBlue members are not required to seek prior approval of emergency services.
Emergency transport and emergency services
Emergency transportation and related medical emergency services provided by a licensed ambulance vendor in connection with an emergency condition are considered to be emergency services and therefore are covered without authorization.
Note that specific rules apply to coverage of paramedic intercept services in both emergent and non-emergent situations. See Medicare Advantage
Medical Policy Bulletin T-2 for full explanation of these rules.
Facilities’ responsibility in emergency situations
For emergency situations, facilities are not required to contact HMS before rendering care. However, if the emergency visit results in an inpatient admission, the hospital is required to obtain authorization of the admission on the next HMS business day.
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Provider Guide to FreedomBlue
Outpatient services requiring authorization
Certain outpatient services require authorization for members with coverage under FreedomBlue. They include the following:

Certain outpatient surgeries (see below)

Outpatient rehabilitation therapies

Home health care

Oxygen supplies and equipment

Outpatient mental health and substance abuse treatment services

Selected durable medical equipment
The official listing of outpatient services requiring authorization is available to providers via the Blue Cross of Northeastern Pennsylvania-hosted NaviNet portal or Secure Access or the Highmark-hosted NaviNet system. (Please note that since this on-line listing applies to all Highmark products, it does not include codes for outpatient rehabilitation therapies, which require authorization only under Medicare Advantage products. Nevertheless, physical medicine, occupational therapy, speech therapy and spinal manipulation therapy do indeed require authorization for FreedomBlue members.)
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Provider Guide to FreedomBlue
Outpatient therapy services
Under FreedomBlue, authorization is required for physical medicine, occupational therapy or speech therapy (“outpatient therapy services”).
Authorizing 12 or fewer visits for outpatient therapy services
Authorization is required for 12 or fewer outpatient therapy services. To obtain authorization of a course of treatment expected to require 12 visits or fewer, contact Healthcare Management Services (HMS) to communicate the basic information listed below, before providing the service :

Patient demographic information (member name, ID number, type of coverage)

Number of visits requested

Diagnosis for which the services are being requested
This information provides a basis for the authorization and establishes a record of the treatment request. This can be particularly important if the provider later needs to request additional visits for this member.
Contacting
HMS by phone
HMS can be reached at (866) 731-8080 for authorization of 12 or fewer outpatient therapy services.
Authorizing more than 12 outpatient therapy visits
When the member’s treatment is expected to require more than twelve outpatient therapy visits, the provider is required to submit a Plan of
Treatment in order to obtain authorization of the therapy services.
The same requirement applies to the situations below:
 When the facility’s therapy staff believes that a member whose initial course of treatment required 12 visits or fewer now requires more than these 12 visits

When a member already receiving therapy services will begin a new course of treatment because a new body part has become involved, and this addition will extend treatment beyond the 12-visit threshold
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Provider Guide to FreedomBlue
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For the thirteenth visit and beyond
Facilities are required to submit a detailed plan of treatment for the thirteenth visit and beyond. To allow adequate time for processing of the continuation request, facilities should submit the plan of treatment as soon as they are aware of the need for ongoing therapy services.

Facilities with Highmark Blue Shield NaviNet submission capability should use that system for this purpose.

Facilities without access to this function should fax the detailed treatment plan for the thirteenth and subsequent visits to any of the fax numbers listed below:
(888) 236-6321
Treatment Plan submission via
NaviNet
Hospital Therapy departments which have been set up to submit their treatment plans via the Highmark Blue Shield NaviNet application should use that system’s treatment plan submission function to communicate the basic information necessary to request authorization of a course of treatment.
Treatment Plan submission via fax
Hospital Therapy departments which have not been set up to submit treatment plans via the Highmark Blue Shield NaviNet application can fax their detailed Plans of Treatment to HMS at any of the fax numbers listed below:
(888) 236-6321
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Provider Guide to FreedomBlue
Submitting a request for authorization of medical services
Facilities ordinarily submit their authorization requests for medical services via a telephone contact with Healthcare Management Services at (866) 731-
8080.
If the authorization is not in place at the time of service
In most cases other than emergency admissions, the member’s primary care physician or attending physician should have completed the authorization process before a scheduled admission or outpatient procedure/service.
However, if a FreedomBlue member presents him- or herself for nonemergency services and the required authorization has not been provided, the facility has the following options:

Review the status of the authorization request via the Highmark Blue
Shield-hosted NaviNet application if the facility has access to this system and make a decision based on the information provided

Call the ordering physician to inquire about the status of the authorization request and make a decision based on this conversation.

Contact Healthcare Management Services on behalf of the ordering physician, to determine whether the review has been completed and an authorization provided. If this has not yet occurred, the facility can initiate this process.
If services are rendered without required authorizations
If a facility renders a service without having obtained the required authorization, the associated claim will be rejected and the member cannot be billed for the service. In order to have the medical necessity of the service or admission reviewed, the facility would need to request a retrospective review.
For information on requesting a retrospective review, please see page 21.
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Provider Guide to FreedomBlue
Authorization processes for outpatient behavioral health
For FreedomBlue members authorization is required for all covered outpatient mental health and substance abuse treatment services.
Separate authorization processes apply to initial and continuing treatment services.
Authorization of initial services
Within three days of a member’s initial evaluation, the provider is required to call Highmark Blue Shield’s Behavioral Health unit, at 1-866-731-8080 to supply initial demographic and clinical information to obtain authorization for services to FreedomBlue members.
The Highmark Blue Shield Behavioral Health unit will verify availability of benefits, assign a case number and authorize the initial evaluation and a number of follow-up treatment sessions. An authorization letter will be sent to the behavioral health provider for the initial span of outpatient treatment sessions.
Authorization of continuing services
Two weeks prior to the full utilization of this initial set of authorized sessions, the provider must contact Highmark Blue Shield’s Behavioral Health unit at
1(866) 731-8080 for continuation of treatment.
The Continuation of Treatment Form must be submitted via fax to the
Highmark Blue Shield Behavioral Health unit at (866) 236-6321.
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Provider Guide to FreedomBlue
Benefits In the course of the authorization process, the HMS reviewer will assist the facility by verifying that the member’s benefit program provides the specific benefits required for the service he or she plans to receive.
When benefit limitations apply
Some benefits are impacted by program provisions such as session/service limits. The number of sessions actually available to the member at the time of the authorization decision depends upon both the total number provided by the member’s benefit program and the number of services already received during this benefit year. Decisions are based on benefit utilization and claim payment information available to the HealthCare Management or Highmark
Blue Shield Behavioral Health reviewer at the time the request for coverage approval is received. However, as this information is subsequently updated, the availability of benefits may change, and a claim based on a service for which a written Notice of Coverage Approval was previously issued may ultimately be denied. In these situations, the member can be billed for the service which exceeded available benefits.
Benefit information via
NaviNet
Benefit information is also available to providers via the Blue Cross of
Northeastern Pennsylvania-hosted NaviNet Blue Exchange function or the
Highmark Blue Shield-hosted NaviNet Eligibility and Benefits function. If for any reason NaviNet is unavailable, contact the Provider Service Center at
1-866-588-6967, from 8:30 a.m. through 4:30 p.m., to obtain the information.
If the benefit is not available or coverage is exhausted
Please be aware that if the member’s benefit program does not provide the specific benefit for the service he or she plans to receive, or if the member’s benefit coverage has been exhausted, Highmark Blue Shield will not reimburse your facility for that service.
If the member insists on receiving the service after having been told that it will not be covered, a pre-service denial (Advanced Beneficiary Notice) must be provided to him or her. This is ordinarily handled by the ordering physician. In this circumstance only , when the member has been formally apprised of the non-coverage of the service and the fact that he or she has the right to appeal, the FreedomBlue member can be billed for the service.
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Provider Guide to FreedomBlue
Two types of denials
Facilities treating FreedomBlue members may experience two types of denials, as detailed in the table below:
Who issues the denial? Denial Type
Benefit denials
Description
Issued when the member’s benefit program does not provide the specific benefit needed for a particular admission or service
The HMS Care or Case
Manager (or, in limited situations, a Member
Service representative) may issue benefit denials
Medical necessity denials
Issued when the requested admission or service does not meet medical necessity criteria
Only a physician can make the decision to deny a service or admission on the basis of medical necessity.
Denial notifications
Facilities may receive verbal and/or written notification of all denial decisions. Written notifications are mailed to the facility within one business day of the decision.
Information in the denial letter
As required by regulatory and accreditation agencies, FreedomBlue’s denial letters contain very specific information, including the following:

The reason for the denial

The clinical rationale supporting the decision

Suggested alternative level of care, if appropriate

Suggested alternatives for treatment if benefits are exhausted

Member and provider appeal process
“Peer to peer” process
If the treating or ordering physician did not have an opportunity to discuss a case with the clinical peer reviewer before a utilization management decision was made about it, he or she may request a peer-to-peer conversation after the decision has been rendered.
To initiate the request, the physician should call, toll-free, (866) 634-6468. A clinical peer reviewer will be available to discuss the case with the treating or ordering physician within one business day.
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Provider Guide to FreedomBlue
Retrospective review: a description
Retrospective review is the post-service assessment of the appropriateness of medical services provided to a FreedomBlue member and completed without prior authorization from Healthcare Management Services (HMS).
When and why retrospective review may occur
Important!
Facilities have a contractual obligation to cooperate fully with admission and outpatient service review procedures. If a facility fails to comply with preadmission procedures or an outpatient authorization requirement, Highmark
Blue Shied has the right to review such admissions or services retrospectively for medical necessity and to deny payment if appropriate.
If payment is denied in such situations, the facility must hold the member harmless – that is, it may not bill the member for the services.
Requesting a retrospective review
In order to receive a retrospective review of an admission or service provided without the appropriate authorization, a facility should follow these steps:
Step Action
1 Submit a claim for the service, according to normal procedures.
Because no authorization is on file for the service, Highmark
Blue Shield claims processing system will reject this claim.
2 When the denial notification is received (via the remittance advice), submit complete medical records and a cover letter explaining the circumstances, to the address below:
Highmark Inc.
Medical Review
P.O. Box 2147
Pittsburgh, PA 15230-2147
Timeframe for completion of retrospective reviews
Retrospective reviews are completed within 30 calendar days from receipt of a facility’s request.
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Provider Guide to FreedomBlue
Special denial processes apply to FreedomBlue
Because of CMS’s concern that the senior population may be intimidated by the health care system and its professionals, it has put regulations in place to ensure that members of Medicare Advantage plans such as FreedomBlue know and use their right to appeal denials of service.
When the member wants a service which cannot be provided under
FreedomBlue
The regulation
There may be times when a FreedomBlue member requests a certain treatment or service which cannot be authorized or provided under the
FreedomBlue program. This could occur in any of several ways:

The member may call Customer Service to ask whether the service is covered, and the Customer Service representative may need to tell the member that there is no benefit for the service.

The member may ask a physician to perform a service which that physician believes is not medically necessary or appropriate, or which he or she believes is not covered under FreedomBlue.

The physician or the facility representative may call Healthcare
Management Services (HMS) for authorization of a service the patient has requested, and the HMS Care Manager may believe that medical necessity criteria are not met. The case would then be passed to a Physician
Advisor for approval or denial. The Physician Advisor may deny approval for the service because medical necessity criteria are not met.
Whenever a member is denied a service he or she believes should be provided by Medicare/FreedomBlue, he or she must be advised in writing of his or her right to appeal that denial of service.
Not usually a facility process
Ordinarily the pre-service denial process is managed by professional providers and Highmark Blue Shied internal staff. It is addressed here primarily so that providers may be aware of it in case members discuss the topic with hospital staff.
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Provider Guide to FreedomBlue
Process only applicable to
FreedomBlue
The process described below applies only to members with coverage under
FreedomBlue (or to their legal representatives if they are not competent to participate).
Process as described below only applicable to hospitals
Please note that the notification process as described below applies only to hospitals. Similar notification requirements and procedures apply to skilled nursing facilities and home health agencies, but these differ from the hospital requirement and process. Skilled nursing facilities and home health agencies should follow the procedures specific to them, as described in pages 25 through 32.
NODMAR: when the member disagrees with the discharge decision
The Centers for Medicare and Medicaid Services (CMS) requires the issuance of a Notice of Discharge and Medicare Appeal Rights ( NODMAR ) form to any Medicare Advantage member who disagrees with the decision to discharge him or her from the hospital to a lower level of care. This form documents the hospital discharge decision, informs the member of his or her potential liability if inpatient services are continued and provides instructions on filing an appeal.
Assistance from facilities in issuing the
NODMAR
According to CMS regulations, Highmark Blue Shield is ultimately responsible for distribution of the NODMAR form to its Medicare Advantage members. As allowed by these regulations, however, Highmark Blue Shield has requested facilities’ assistance in distributing and explaining the form to members in a timely fashion. Highmark Blue Shield collaborates with facilities in this task.
Prompt notice The member should be notified and the NODMAR process should be initiated as soon as the discharge decision is made.
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Provider Guide to FreedomBlue
Continued
The NODMAR process
Please use the procedure described below, each time a FreedomBlue member disagrees with the decision to discharge him or her from your facility.
Remember that if the member is not competent to understand and sign the
NODMAR form, it can be completed by the member’s legal or appointed representative.
Step
1
2
3
4
5
6
Action
As soon as the member or his or her representative communicates disagreement with the discharge decision, prepare the NODMAR form for signature.
Obtain the member’s/representative’s signature on the form. Explain the appeal options available to the member.
Give a copy of the signed NODMAR form to the member.
Maintain a copy of the signed NODMAR form in the member’s permanent medical record.
Fax a copy to the Quality Improvement Organization at the number indicated on the form.
If requested (by either HMS or the Quality Improvement
Organization), provide medical records in a timely manner to assist with the member’s appeal. A copy of the NODMAR form is ordinarily requested to accompany the medical records.
Member financial liability
Current QIO
Please note that the Medicare Advantage member’s financial liability for services does not begin until 24 hours after the NODMAR is given, unless the member appeals the discharge to the Quality Improvement Organization
(QIO). If the member does appeal to the QIO and that organization concurs with the discharge, the member refusing discharge becomes liable for services beginning at noon on the day after the QIO communicates its decision to the member.
The current (July, 2004) QIO is Quality Insights of Pennsylvania.
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Provider Guide to FreedomBlue
Process specific to skilled nursing facilities
The process described below is specific to skilled nursing facilities. Similar processes apply to hospitals and home health agencies. (See pages 23-24 and
29-32, respectively, for more information.)
NOMNC: an overview
The Notice of Medicare Non-Coverage (NOMNC) form provides members with their notification of discharge and member appeal rights. Two days prior to discharge, skilled nursing facilities are required to distribute the
NOMNC form to FreedomBlue members (or their legal representative).
Content of the form
The form contains the discharge information and a Quality Improvement
Organization (QIO) phone number that the member can use if he or she wishes to initiate an appeal of the discharge decision. The member or legal representative must sign this form.
NOMNC: the steps and responsibility for completing the process
The following table outlines the responsibilities associated with the distribution of the NOMNC form.
Step Action
1 The facility distributes the Notice of Medicare Non-Coverage to the member at least two days prior to discontinuation of skilled care.
2 The member (or legal representative) signs the form to indicate that he or she has received it. The member must be able to understand the purpose and contents of the Notice in order to sign for receipt of it. If the member does not agree with the decision, he or she can initiate an appeal by contacting the designated Quality
Improvement Organization (QIO), as described in the form.
3
4
The facility provides a copy of the form to the member and keeps another copy for their medical records.
If the member disagrees with the discharge decision, the facility faxes a copy of the signed form to FreedomBlue at 800-894-7947.
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Provider Guide to FreedomBlue
Continued
NOMNC: the steps and responsibility for completing the process (continued)
Step Action
5 On the date that the QIO receives notification that the member has appealed the decision, it will notify both the provider and
Highmark that the member has requested an immediate review.
6
7
8
Before close of business on the date of the appeal, the facility will supply the QIO with the signed form, all applicable medical records and any other information that the QIO may request.
Before close of business on the date of the appeal, Highmark supplies the member with a Detailed Explanation of Non-
Coverage (DENC).
After it receives all of the necessary information from Highmark and the provider, the QIO solicits the view of the member who requested the review and makes a determination whether an extension of services is medically necessary. The QIO will typically render a decision prior to the termination of services. If all of the required information is not delivered in the requested time frame, the QIO may make its decision based on the information available, or defer to a later date.
Valid delivery of the NOMNC
For delivery of the NOMNC to be valid, the member must be able to understand the purpose and contents of the notice in order to sign for it. The member must also be able to understand that they can appeal the discharge decision.
Authorized or legal representative
If the member is incompetent or incapacitated, the NOMNC must be delivered to and signed by his or her legal or authorized representative.
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Provider Guide to FreedomBlue
Continued
Definitions

Legal Representative – any individual who has legal responsibility for an incompetent or incapacitated member’s affairs. A legal representative can act on the member’s behalf in initiating and carrying out an appeal without further designation to this role by the member.

Authorized Representative – any individual authorized by the member, or surrogate who is acting in accordance with state law on behalf of the member. An authorized representative can act on the member’s behalf only if the member has signed a statement that this is what he or she wants.
When the legal or authorized representative is not present to receive the
NOMNC
When the FreedomBlue member’s legal or authorized representative is not present to receive the NOMNC in person, the facility is responsible for contacting that individual by telephone and documenting the date and content of the conversation on the form. The date of the conversation is considered the date of receipt of the NOMNC.
If direct telephone contact cannot be achieved, the notice should be sent to the representative by certified mail, return receipt requested. The signature date for receipt of the letter is considered the date of receipt of the NOMNC.
Member liability if he or she agrees with discharge decision
If the member agrees with the discharge decision, he or she signs the
NOMNC and there is no member liability. (Signing the form indicates receipt of the document and understanding of the contents; it does not signify acceptance of the decision.)
Member liability if he or she disagrees with the discharge decision
If the QIO overturns the decision made by the health plan, the member will have no liability. If the QIO upholds the decision made by the health plan, the member may be liable for one day’s services if he or she chooses to continue receiving services until the day after the QIO’s decision is received.
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Provider Guide to FreedomBlue
Continued
Member liability if the deadline for appeals is missed
If the member misses the deadline for appealing to the QIO, and the appeal goes directly to the health plan, there is no financial protection during the course of the appeal.
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Provider Guide to FreedomBlue
Process specific to home health agencies
The process described below is specific to home health agencies. Similar processes apply to hospitals and skilled nursing facilities. (See pages 23-24 and 25-28, respectively, for more information.)
NOMNC: an overview
The Notice of Medicare Non-Coverage (NOMNC) form provides members with their notification of discharge and member appeal rights. Two days prior to discharge, or the visit before the last scheduled visit, home health agencies are required to distribute the NOMNC form to FreedomBlue members (or their legal representative). If fewer than two visits are scheduled, the NOMNC should be distributed on the first visit.
Content of the form
The form contains the discharge information and a Quality Improvement
Organization (QIO) phone number that the member can use if he or she wishes to initiate an appeal of the discharge decision. The member or legal representative must sign this form.
NOMNC: the steps and responsibility for completing the process
The following table outlines the responsibilities associated with the distribution of the NOMNC form.
Step Action
1 The agency distributes the Notice of Medicare Non-Coverage to the member on the next to last visit.
2 The member (or legal representative) signs the form to indicate that he or she has received it. The member must be able to understand the purpose and contents of the Notice in order to sign for receipt of it. If the member does not agree with the decision, he or she can initiate an appeal by contacting the designated
Quality Improvement Organization (QIO), as described in the form.
3
4
The agency provides a copy of the form to the member and keeps another copy for their medical records.
If the member disagrees with the discharge decision, the agency faxes a copy of the signed form to FreedomBlue at 800-894-7947.
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Provider Guide to FreedomBlue
Continued
NOMNC: the steps and responsibility for completing the process (continued)
Step Action
5 On the date that the QIO receives notification that the member has appealed the decision, it will notify both the provider and
Highmark Blue Shield that the member has requested an immediate review.
6
7
Before close of business on the date of the appeal, the agency will supply the QIO with the signed form, all applicable medical records and any other information that the QIO may request.
Before close of business on the date of the appeal, Highmark Blue
Shield issues the member a Detailed Explanation of Non-Coverage
(DENC).
8 After it receives all of the necessary information from Highmark
Blue Shield and the provider, the QIO solicits the view of the member who requested the review and makes a determination whether an extension of services is medically necessary. The QIO will typically render a decision prior to the termination of services.
If all of the required information is not delivered in the requested time frame, the QIO may make its decision based on the information available, or defer to a later date.
Valid delivery of the NOMNC
For delivery of the NOMNC to be valid, the member must be able to understand the purpose and contents of the notice in order to sign for it. The member must also be able to understand that they can appeal the discharge decision.
Authorized or legal representative
If the member is incompetent or incapacitated, the NOMNC must be delivered to and signed by his or her legal or authorized representative
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Provider Guide to FreedomBlue
Continued
Definitions

Legal Representative – any individual who has legal responsibility for an incompetent or incapacitated member’s affairs. A legal representative can act on the member’s behalf in initiating and carrying out an appeal without further designation to this role by the member.

Authorized Representative – any individual authorized by the member, or surrogate who is acting in accordance with state law on behalf of the member. An authorized representative can act on the member’s behalf only if the member has signed a statement that this is what he or she wants.
When the legal or authorized representative is not present to receive the
NOMNC
When the FreedomBlue member’s legal or authorized representative is not present to receive the NOMNC in person, the facility is responsible for contacting that individual by telephone and documenting the date and content of the conversation on the form. The date of the conversation is considered the date of receipt of the NOMNC.
If direct telephone contact cannot be achieved, the notice should be sent to the representative by certified mail, return receipt requested. The signature date for receipt of the letter is considered the date of receipt of the NOMNC.
Member liability if he or she agrees with discharge decision
If the member agrees with the discharge decision, he or she signs the
NOMNC and there is no member liability. (Signing the form only indicates receipt of the document and understanding of its contents; it does not signify acceptance of the decision.)
Member liability if he or she disagrees with the discharge decision
If the QIO overturns the decision made by the health plan, the member will have no liability. If the QIO upholds the decision made by the health plan, the member may be liable for one day’s services if he or she chooses to continue receiving services until the day after the QIO’s decision is received.
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Provider Guide to FreedomBlue
Continued
Member liability if the deadline for appeals is missed
If the member misses the deadline for appealing to the QIO, and the appeal goes directly to the health plan, there is no financial protection during the course of the appeal.
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Provider Guide to FreedomBlue
When facilities can use the
Provider
Appeal process
A facility can make use of this Provider Appeal process when all of the following are true:

The member has coverage under FreedomBlue.

The services in question were denied concurrently or retrospectively, rather than on a pre-service basis.

The member is held financially harmless.

The facility seeks a resolution in order to obtain payment for the services.
Types of appeals following a medical necessity denial
When a medical necessity denial decision has been made, including requests for services which are considered experimental/investigational or cosmetic in nature, these types of appeals are available to the provider:

Expedited appeals

Standard appeals
Expedited appeals
Standard appeals
An expedited appeal is a formal review of an initial adverse medical necessity determination. It can be requested when a delay in decision-making may seriously jeopardize the member’s life, health or ability to regain maximum function.
A standard appeal is a formal review of the initial adverse medical necessity determination, in which the conditions for expedited appeal are not met.
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Provider Guide to FreedomBlue
Appeal process: pre-service or concurrent submission
Use the process below when filing an expedited or standard appeal of a preservice or concurrent denial of services when the member has coverage under
FreedomBlue.
Expedited Submission Process Standard Submission Process
How to initiate
Contact HMS at (866) 731-8080, to provide additional information via phone or
Fax the information to HMS at (866)
236-6321.
Contact HMS at (866) 731-8080, or submit all pertinent medical and other information to the address below:
Healthcare Management Services
Appeals Department
P.O. Box 535073
Pittsburgh, PA 15253-5073
When to initiate
Decision timeframe
Prior to discharge from the facility Within 180 days from receipt of the denial
Within 72 hours of the appeal request Within 30 calendar days from receipt of the appeal request
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Provider Guide to FreedomBlue
Appeal process: retrospective denials
Use the process below when filing an appeal of an initial medical necessity denial decision and the service rendered to a FreedomBlue member has already been provided.
Please note that the expedited appeal process is not applicable to post-service requests.
How to initiate
Standard Submission Process
Submit all pertinent medical and other information to the address below:
Highmark Inc.
Medical Review
P.O. Box 2147
Pittsburgh, PA 15230-2147
When to initiate Within 180 days from receipt of the denial notification
Decision timeframe
Within 30 calendar days from the receipt of the appeal request
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Provider Guide to FreedomBlue
When can a facility file an appeal for a
Medicare
Advantage member?
Ordinarily, it is the member or the member’s family who files an appeal if a requested medical service has been denied. However, on rare occasions, a
FreedomBlue member might ask a facility to file the appeal on his or her behalf. A facility can do so for the services only if the member would be financially liable
, on a pre-service basis only.
Representative statement required
In order to file an appeal on behalf of the member, the facility must have written authorization to do so from the member or the individual holding the member’s power of attorney. Without the statement appointing the facility to act as a representative, an appeal cannot be initiated.
There is no official Highmark Blue Shield form for this purpose; the member or power of attorney can write, sign and date his or her own statement appointing the facility as the member’s authorized representative. The representative must also sign the statement indicating acceptance of this responsibility. The written statement must then be forwarded to Highmark
Blue Shield along with the appeal materials.
Exception: physician requests
The member’s physician
(either contracting or non-contracting) can act as the member’s representative without the signed representative statement, in pre-service denial situations which meet the criteria for an expedited request.
Types of preservice appeals
Two types of pre-service appeals are available to a facility following a denial:

Expedited appeals

Standard appeals
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Provider Guide to FreedomBlue
Continued
Expedited appeals: within
72 hours
If the member or his or her authorized representative believes that applying the standard 30-day appeal process would seriously jeopardize the member’s life, health or ability to regain maximum function, an expedited appeal can be requested. The Health Plan reserves the right to determine whether the request meets the criteria for an expedited appeal.
Decisions for expedited appeals are made as expeditiously as the member’s health requires, but no later than 72 hours .
Standard pre-service appeals
Questions
Standard appeals are processed as expeditiously as the member’s health requires, but no later than 30 days .
Standard member appeals (including those filed on the member’s behalf by a facility) are those which may not meet the criteria for an expedited appeal as determined by the Health Plan, or those in which the member’s health would not be jeopardized by the standard 30-day time frame.
For questions about Medicare Advantage expedited appeal processes, please contact HMS at (866) 803-3708.
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Provider Guide to FreedomBlue
Appeal of a pre-service or concurrent denial decision
How to initiate
When to initiate
Decision timeframe
Use the processes defined below when Healthcare Management Services
(HMS) has been contacted and a denial has been received by the member before the service was rendered or while the service is being performed. Note that the member has the option to file an appeal to the Quality Improvement
Organization for continued acute stays. Further instructions are available on the member’s denial letter (Notice of Denial of Medical Necessity) or Notice of Denial and Medicare Appeal Rights (NODMAR) form.
Expedited Submission Process
Contact HMS at (866) 803-3708, or
Fax the request to HMS at (800) 416-
9195
Mail the request and all pertinent medical information to this address:
Healthcare Management Services
Medicare Advantage
Appeals Department
P.O. Box 535073
Pittsburgh, PA 15253-5073
For pre-service requests : Before rendering the service
For concurrent requests : Before the member’s discharge from the facility
Within one business day, not to exceed 72 hours of the request.
Extensions of up to 14 days may be requested by the Health Plan or by the facility, on the member’s behalf.
Standard Submission Process
Fax the request to the Medicare
Advantage Appeals Department at (412)
544-1513, or
Mail the request and all pertinent medical information to this address:
Medicare Advantage Appeals Department
P.O. Box 535047
Pittsburgh, PA 15253-5047
Within 180 days from receipt of the denial notification.
If good cause is shown, written requests can be accepted for standard reconsiderations filed after 180 calendar days.
As expeditiously as the member’s health requires, but no later than 30 calendar days from the receipt of the appeal request.
An extension of 14 days may be requested by the Health Plan or by the facility, on the member’s behalf.
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Provider Guide to FreedomBlue
Continued
If an adverse decision is rendered
When the Health Plan renders an adverse decision on an appeal filed by a facility on behalf of a FreedomBlue member, Highmark Blue Shield automatically forwards the case to Medicare’s Reconsideration Agent for further review. A letter is sent to the member or the member’s representative advising of the forwarding of information to the Reconsideration Agent.
If the member is not satisfied with the decision of the
Reconsideration
Agent
If the Medicare Reconsideration Agent also renders an adverse decision and the member continues to disagree, he or she has the right to initiate further action. The denial communication from the Reconsideration Agent includes information about these options.
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Provider Guide to FreedomBlue
Nonparticipating facilities only
The appeal process described below is applicable only to those facilities which do not participate with FreedomBlue.
(By contract, Medicare
Advantage participating facilities cannot file appeals for claim denials.)
When a non- participating facility can file an appeal
A non-participating facility can file a standard appeal for a denied claim only if it is acting as the member’s officially-designated representative or if it submits a Waiver of Liability statement. The Waiver of Liability states that the provider will not bill the Medicare Advantage member regardless of the outcome of the appeal.
Appeal of a post-service denial decision:
Nonparticipating providers only
Facilities which do not participate with Highmark Blue Shield in association with Blue Cross of Northeastern Pennsylania’s Medicare Advantage product should follow the process below when filing a post-service appeal request for a FreedomBlue member. Please note that this is the standard submission process; the expedited process does not apply to post-service requests.
Standard Submission Process
How to initiate Submit all pertinent medical and other information to the address below:
Medicare Advantage FreedomBlue Appeals
Department
P.O. Box 535047
Pittsburgh, PA 15253-5047 or
Fax the information to the Appeals department at (412)
544-1513
When to initiate Within 180 days from the receipt of the denial notification. If good cause is shown, written requests can be accepted for standard reconsiderations filed after 180 calendar days.
Decision timeframe
Within 30 calendar days but no later than 60 days from receipt of the appeal request
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Provider Guide to FreedomBlue
Important telephone numbers
The table below identifies telephone numbers which may be useful to facilities which service members with coverage under FreedomBlue:
When you need…
Answers to provider questions about
FreedomBlue
Information about
FreedomBlue member benefits if NaviNet is unavailable
To obtain authorization of a medical admission or one of the outpatient medical services requiring authorization
To obtain authorization of behavioral health services
To initiate an expedited or standard appeal of an initial adverse medical necessity decision -- concurrent procedure
To submit an appeal of a pre-service or concurrent denial on behalf of a
FreedomBlue member
Contact…
Provider Relations
Provider Service Center (866) 588-6967
Healthcare
Management Services
(HMS)
Highmark Blue Shield
Behavioral Health Unit
Healthcare
Management Services
(HMS)
Healthcare
Management Services
(HMS)
At this number…
(800) 451-4447
(866) 731-8080
(866) 731-8080
(866) 803-3708
Contact HMS at (866)
803-3708, or
Fax the request to HMS at (412) 544-1513
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Provider Guide to FreedomBlue
Important telephone numbers (continued)
When you need…
To initiate a peer-to-peer discussion for an ordering physician with a FreedomBlue clinical peer reviewer
Obtain authorization of durable medical equipment, orthotics, prosthetics and respiratory equipment
(including oxygen)
Contact…
Physician Advisor
Office
Wright and Filippis
At this number…
(866) 634-6468
(877)-345-4774
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