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    • Trek Health
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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyBeacon Health Options Reimbursement Update | OpenP…
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    CurrentBeacon-Health-OptionsPolicy N/A

    Out-of-Network Provider Services Terms and Conditions

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    This policy governs reimbursement and provider obligations when Carelon Behavioral Health authorizes specified out-of-network services for members across Medicaid, Medicare, and Commercial products.

    Policy Summary
    PayerBeacon-Health-Options
    PolicyOut-of-Network Provider Services Terms and Conditions
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDec 5, 2023
    Next Review DateN/A
    Key ActionAccept reimbursement at 100% of applicable Medicaid or Medicare allowable rates, legally required rates, state-approved methodologies, or applicable Carelon fee schedules as payment in full for authorized covered services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    100%Medicaid and Medicare authorized services
    100%Commercial authorized services
    No SCASCA for Medicaid/Medicare and eligible Commercial accounts
    Cost shareCommercial access-case exception

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    No paymentExcluded-provider services

    Authorized Out-of-Network Reimbursement

    Authorized out-of-network service reimbursement

    Reimbursement is available for authorized covered services, subject to product type, plan benefit design, applicable law, state-approved payment methodologies, and the specific conditions below.

    ALL of the following

    • Services are authorized by Carelon.
    • Services are covered under the applicable Medicaid, Medicare, or Commercial benefit.
    • The provider accepts the applicable allowable rate, fee schedule rate, legally required rate, or state-approved payment methodology.

    Restrictions and compliance conditions

    Payment and provider billing rights are limited by emergency-service requirements, network access circumstances, coverage status, and provider compliance.

    ANY of the following

    • For an inpatient emergency admission, applicable authorization or review requirements are satisfied, including post-stabilization or continued-stay requirements when applicable.
    • For a network access authorization, the provider bills only Carelon except for applicable member cost share.
    • For non-covered services, the provider has informed the member about covered alternatives and obtained the member's written agreement to be billed.
    • The provider is licensed, not excluded from applicable government healthcare programs, and complies with applicable standards.

    Provider Reimbursement and Compliance Obligations

    Billing Rule

    Medicaid and Medicare Reimbursement

    Accept reimbursement for authorized Medicaid and Medicare covered services at 100% of applicable Medicaid or Medicare allowable rates, or at the rate required by applicable law, regulation, state-approved payment methodology, or Carelon fee schedule. This payment must be accepted as payment in full for the services, and Carelon will not require an SCA.

    Billing Rule

    Commercial Reimbursement and SCA Requirements

    For authorized Commercial covered services, accept reimbursement at 100% of the Carelon Behavioral Health Fee Schedule consistent with the plan benefit design, or at the rate required by applicable law, regulation, or state-approved payment methodology. For out-of-network services approved due to an access issue, accept payment in full except for applicable Member Cost Share; a countersigned SCA is required for Commercial Accounts without out-of-network benefits, but not for accounts with such benefits.

    Key Policy Terms

    Member Cost Share
    Member Cost ShareA member deductible, copayment, or coinsurance.
    DeductibleA form of Member Cost Share.
    CopaymentA form of Member Cost Share.
    CoinsuranceA form of Member Cost Share.
    Applicable Standards
    Carelon referralCarelon referral requirements applicable to the provider's services.
    Quality assuranceCarelon quality assurance requirements applicable to the provider's services.
    Policy Summary
    PayerBeacon-Health-Options
    PolicyOut-of-Network Provider Services Terms and Conditions
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateDec 5, 2023
    Next Review DateN/A
    Key ActionAccept reimbursement at 100% of applicable Medicaid or Medicare allowable rates, legally required rates, state-approved methodologies, or applicable Carelon fee schedules as payment in full for authorized covered services.
    SourceLink
    On This Page
    Authorized Out-of-Network ReimbursementProvider Reimbursement and Compliance ObligationsKey Policy Terms
    Prior Authorization

    Emergency Inpatient Review Requirements

    For inpatient emergency admissions, comply with applicable out-of-network authorization requirements and any notification, authorization, or continued-stay review requirements for post-stabilization or subsequent inpatient services. Apply the Member’s in-network cost share when required by applicable federal or state requirements, including the No Surprises Act.

    Denial Risk

    Applicable Standards for Authorized Services

    Provide medically necessary services within your specialty in accordance with generally accepted medical standards, applicable laws and regulations, cost-effective practices, and Carelon referral, quality assurance, and utilization management policies and procedures. Authorization may be terminated for failure to comply with these Applicable Standards.

    Denial Risk

    Network Access Issue Payment Restriction

    When authorization is granted because of a network access issue, look solely to Carelon for payment for covered services and do not seek or accept payment from the Member, the Member’s representative, any state department, agency, or subdivision, or any plan. The only exception is applicable Member Cost Share.

    Billing Rule

    Member Billing for Non-Covered Services

    Do not seek or accept payment from the Member for non-covered services unless you first inform the Member that covered services are available, the Member declines those covered services, and the Member agrees in writing to be billed for the non-covered services.

    Denial Risk

    Licensure and Exclusion Obligations

    Maintain required licensure and immediately notify Carelon if your license is restricted, suspended, or revoked. Do not provide services to, receive payment from, or contract with Medicare, Medicaid, or another federal or state healthcare program while excluded; Carelon will not reimburse services rendered during an exclusion period.

    Utilization managementCarelon utilization management policies and procedures applicable to the provider's services.
    Medical necessityThe provider must provide medically necessary services.
    Legal and regulatory requirementsAll applicable laws and regulations.
    Provider specialtyServices must be within the provider's specialty.
    Generally accepted medical standardsServices must be provided in accordance with generally accepted medical standards.