Pages Menu
Categories Menu

Posted by on Aug 14, 2014 in Education, Small Business, Small Group

Out-of-Network Reimbursement Guidelines

Out-of-Network Reimbursement Guidelines

Written by Robert Guenther, HIP Pre-Sale Support Specialist Warner Pacific Insurance Services

This applies to California Small Group Plans.

From the plan summary: For out-of-network care, Aetna limits the amount it will pay. The limit is called the recognized or allowed amount. Aetna recognizes an amount based on what Medicare pays for these services. The government sets the Medicare rate.

From the website: The plan pays 105% of the Medicare rate.

From EOC: Providers who are not contract with Anthem and are not in any of their networks are out-of-network providers (OON) or other eligible providers (OEP), subject to Blue Cross Blue Shield Association rules governing claims filed by certain ancillary providers. For covered services received from an OON provider/OEP, other than emergency care within California, the maximum allowed amount will be based on:

  1. Applicable Anthem OON provider/OEP rate or fee schedule for your plan.
  2. Amount negotiated by Anthem or a 3rd party which has been agreed to by the OON provider/OEP.
  3. The total charges billed by the OON provider/OEP.
  4. Information provided by a third party vendor.
  5. Reimbursement or cost information from the Centers for Medicare & Medicaid Services (CMS). When basing the maximum allowed amount upon the level or method of reimbursement used by CMS, Anthem will update such information, which is unadjusted for geographic locality, no less than annually.

From summary: Coinsurance is calculated based on the allowable amount unless otherwise specified. For covered services by non-preferred and non-participating providers, you are responsible for all charges above the allowable amount.

From EOC: The allowable amount is the total amount Blue Shield allows for covered services rendered, or the provider’s billed charge for those covered services, whichever is less. The allowable amount, unless specified for a particular service elsewhere is: For a participating provider, the amount the provider and Blue Shield have agreed on by contract will be accepted as payment in full for the covered services. For a non-participating provider who provides emergency services, anywhere within or outside of the United States:

  1. Physicians and Hospitals – Reasonable and Customary charge.
  2. All other providers – provider’s billed charge for covered services, unless the provider and the local BCBS Plan have agreed upon some other amount.

For a non-participating provider in California who provides services (other than emergency):

  1. The amount Blue Shield would have allowed for a participating provider performing the same service in the same geographical area; or
  2. Non-participating dialysis center for services prior authorized by Blue Shield, the amount is the Reasonable and Customary charge.

From EOC: For services or supplies provided by an OON provider, the amount payable is based on HN’s limited fee schedule for OON providers, which is based on relative value unit schedule and dollar amount conversion factors.

From EOC: The allowed amount for OON claims is equal to 110% of Medicare allowable rates. Only the allowed amount is applied to the OON deductible and/or OOPM. Insured will be responsible for any billed charges in excess of the Medicare allowed rate.

From EOC: Reimbursement policy guidelines are developed in accordance with one or more of the following methodologies:

  • As indicated in the most recent edition of the CPT and/or the CMS. • As reported by generally recognized professionals or publications.
  • As used for Medicare.
  • As determined by medical staff and outside medical consultants pursuant to other appropriate sources or accepted determinations.

Covered California is currently reviewing its entire training program and will be offering supplemental education through e-learning and other methods to help support enrollment efforts. Certified Insurance Agents are encouraged to make use of these resources when they become available.  Continued training will help to ensure you have the latest updates on the individual and SHOP marketplaces as well as our policy and guidelines.