Use of a Nonparticipating Care Provider in Facility Settings
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This administrative policy governs how participating facilities in Empire Bluecross/Anthem's New York commercial network must manage use of nonparticipating care providers when providing inpatient or outpatient facility-based services, and the corrective measures that may be applied. It affects Anthem participating facilities and their billing/administrative practices related to member care routing.
An administrative penalty equal to 7.5% of the allowed amount of the facility's claim that involves the use of nonparticipating care providers was instituted.
Potential termination from Anthem networks for participating facilities that allow use of nonparticipating care providers in facility-based settings was specified as a corrective measure.
Participating facilities may not balance bill members for any reduction in payment related to the penalty.
Specified exceptions where nonparticipating care providers may be permitted: emergency services; prior-approved use; no available participating provider in same geographic area; rural hospitals; critical access hospitals; safety-net hospitals.
Use of Nonparticipating Care Providers — Policy Criteria
Facility use of nonparticipating care providers
Policy stance and enumerated exceptions for permitting nonparticipating care providers in facility-based settings:
ALL of the following
ALL of the following
- Administrative penalty equal to 7.5% of the allowed amount of the facility's claim that involves the use of nonparticipating care providers
Applied to the facility's claim
- Potential termination from Anthem networks
Enforcement option for noncompliance
Exceptions (no penalty when one or more apply)
- Emergency services
- Anthem has granted prior approval for use of a nonparticipating care provider in the facility-based setting
- No participating care provider is available to render the same services within the same geographic area
- Facility is a rural hospital as defined by the Health Resources & Services Administration (HRSA)
- Facility is a critical access hospital as defined by the Centers for Medicare & Medicaid Services (CMS)
- Facility is a safety-net hospital (defined as hospitals at or above the 75th percentile of the proportion of Medicare beneficiaries who are dually eligible for Medicare and Medicaid across all acute care hospitals)
Coding & Financial Parameters
| No codes listed |
Provider Responsibilities & Corrective Measures
Prior approval exception
Participating facilities may use a nonparticipating care provider in a facility-based setting only when Anthem has granted prior approval; prior approval from Anthem is an exception to the policy that would otherwise permit corrective measures against the facility.
- Exception applies to inpatient and outpatient, facility-based settings.
- Prior approval prevents application of the administrative penalty and other corrective measures described in the policy.
No balance billing for penalty-related payment reductions
When an administrative penalty is applied to a facility claim for use of a nonparticipating care provider, participating facilities may not balance bill members for any reduction in payment related to that penalty.
- Applies to payment reductions resulting from use of nonparticipating care providers in facility-based settings.
- This prohibition on balance billing is reiterated as a reminder to participating facilities.
Administrative penalty and potential network termination for noncompliance
Participating facilities that allow nonparticipating care providers to render services in a facility-based setting may be subject to an administrative penalty equal to 7.5% of the allowed amount of the facility's claim and may face potential termination from Anthem networks for noncompliance.
- Administrative penalty: 7.5% of the allowed amount of the facility's claim involving nonparticipating care providers.
- Potential corrective action includes termination from Anthem networks.
Facility Type Definitions & Scope Exceptions
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