Pinnacle Claims Management Health Plan Transparency
Pinnacle is committed to our clients, and as such, we actively work to ensure you receive the necessary guidance as it pertains to legislative changes in health care. There have been several provisions of the Consolidated Appropriations Act of 2021 (CAA) and the Transparency in Coverage Rule that have taken effect, and additional provisions that will go into effect later in 2022 and 2023. Supporting our clients remains one of our most important values, and as part of our commitment to you, we’ve provided guidance to help you remain in compliance with these recent changes. We will continue to work effectively and efficiently to provide you with additional information throughout the year and beyond.
Advanced Explanation of Benefits
Plans that receive pre-service notifications from providers must provide notice to members that include whether the provider or facility is a participating provider. They must also include good faith estimates in the notification from the provider, the amount the plan will pay for the services, the member’s cost share, and the amount the member has incurred toward deductibles and out-of-pocket maximums.
What we’re doing: Pinnacle is currently working on developing the advanced explanation of benefits for scheduled services. The required date for implementation has been deferred by federal agencies pending further rulemaking. Once guidance is received, we will begin implementation of the solution.
Changes to Provider Directories
Health plans are required to maintain up-to-date directories of network providers, which must be available online and accessible to the public or within one business day of inquiry.
What we’re doing: Pinnacle has made provider directories conveniently available for members to access directly on its website: https://live-pinnacle-tpa.pantheonsite.io/find-a-provider/. While regulations require plans to verify and update directories at least every 90 days, Pinnacle will verify and update these directories on a monthly basis.
Reliance on Incorrect Network Directories
There may be instances when a member relies on inaccurate network directory information prior to treatment and receive services from a provider who is no longer a member of the network. In these instances, the plan is required to pay the claims at the in-network rate.
What we’re doing: To mitigate this risk, Pinnacle will update its network directory every month and work with its network partners to provide accurate, up-to-date directory information.
ID Card Requirements
The CAA requires health plans to provide information on ID cards regarding the amount of the in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum limitations, and a telephone number and website address through which individuals may seek consumer assistance information.
What we’re doing: Pinnacle has taken this opportunity to make a number of changes to improve the format of its cards. Our new card design features a more streamlined look for easier readability for both members and providers. The CAA requires that new ID cards be made available to members at renewal, on or after 1/1/2022. Pinnacle has worked to ensure that all ID cards, with the exception of those that have a different pharmacy benefit manager (PBM), have already been distributed to members.
Prohibition of Gag Clauses
A gag clause is a provision of a contract that restricts or prevents insurers from making price or quality information available to members.
What we’re doing: To remain in compliance and improve transparency, Pinnacle has omitted gag clauses from new contracts and will continue to remove gag clauses from existing contracts as they are renewed.
Although this provision became effective December 20, 2020, legislation is still pending on when and how plans are required to submit their plan attestation that the plan is in compliance. Pinnacle will adhere to these provisions when these guidelines are finalized.
Cost-sharing payments made with respect to non-network emergency services or non-emergency services performed by non-par providers in par facilities will be counted toward the member’s network deductible and out-of-pocket maximum in the same manner as if the services were provided by a network provider. The same applies for air ambulance services. If a member relies on an incorrect provider directory and receives services from a provider that is no longer in the network, any payments made will be counted toward the member’s network deductible and out-of-pocket maximum.
What we’re doing: Pinnacle has updated its internal claims processes to remain in compliance with this requirement and, effective January 1, 2022, out-of-network surprise bills are applied to the member’s network deductible.
Plans are required to make the initial payment or denial of claims within 30 days of receipt of the claim.
What we’re doing: Pinnacle has and will continue to pay or deny claims within 30 days of receipt.
Continuity of Care
If a provider changes network status (i.e., leaves the plan’s network), members with certain needs may continue care with the provider for up to 90 days at network cost sharing rates to allow for a transition of care to a network provider.
What we’re doing: Pinnacle is working with its network partners on the processes required to continue continuity of care and has made adjustments to its internal claims processes. Please note, however, that Pinnacle will administer your plan in accordance with your plan document. You should ensure that your SPD is amended to reflect this requirement. Pinnacle can assist with your plan amendment and will suggest draft language that you may adopt.
Expansion of External Review
Plans are required to accommodate requests for external review when the applicability of surprise billing protections are in question.
What we’re doing: Pinnacle has a written protocol to handle these appeals and requests. The member has the right to request review by an Independent Review Organization (IRO) after the appeal process if the applicability of surprise billing protections is in question. However, please note that Pinnacle will administer appeals in accordance with the applicable plan document. Employers should ensure that their SPDs are updated accordingly. Pinnacle can assist with your plan amendment and will suggest draft language that you may adopt.
Disclosure of Balance Billing Rules
Prohibition on balance billing language is required to be posted on the plan’s public website and on each EOB.
What we’re doing: Pinnacle has added this language to its website, and we are currently working on adding this language to every EOB. Additionally, our legal team is working on consolidating the EOB language, as well as using electronic delivery for the full disclosure.
Surprise Bill Ban Independent Dispute Resolution Process
The Federal Independent Dispute Resolution (IDR) process was established to resolve disputes between payers and out-of-network providers only for services where balance billing is prohibited (i.e. when the No Surprises Act applies). Disputing parties must engage in a 30-business-day open negotiation period to attempt to reach an agreement regarding the total out-of-network rate (including any cost sharing). Once the open negotiation period has ended, either party can initiate the IDR process within 4 days. The IDR process will be administered by an arbitrator who will take into consideration payment amounts offered by each party as well as additional considerations (Qualified Payment Amounts, level of training and experience of the provider, etc.). The IDR arbitrator’s decision is binding and the losing party is responsible for paying the arbitrator’s fees (estimated to range from $200-$700), and both parties will pay a $50 administrative fee. IDR fees will be billed to clients on a pass-through basis.
What we’re doing: Pinnacle will administer this process for its clients and provide additional support.
Machine Readable Files
Plans are required to disclose, on a public website, three machine-readable files showing (i) in-network provider rates for covered medical items and services, (ii) out-of-network allowed amounts and billed charges for covered medical items and services, and (iii) negotiated rates and historical net prices for covered prescription drugs.
What we’re doing: Pinnacle will make the required machine-readable files for in-network and out-of-network medical items and services public on HealthView as of the required deadline of July 1, 2022. These are the negotiated rates for in-network services and historical payments and billed charges from out-of-network providers. The third file, rates and historical prices for covered prescription drugs, has been deferred pending further regulation, and will be made available as required by federal law. We will also be linking to our network partners’ files (Anthem Blue Cross, Blue Cross Blue Shield of Arizona, Blue Card, Multiplan, First Health), which are accessible through their websites.
Cost Transparency Tool
Plans are required to make price comparison information available through a web-based self-service tool and in paper form upon request for 500 items and services, for plan years beginning on or after January 1, 2023.
What we’re doing: Pinnacle is actively working on implementing the cost transparency tool for the Cedar plan by the January 1, 2023 deadline. This major technological implementation will enable our members to compare cost-sharing amounts for specific network providers in a specific region. Some of our network partners are also working on updating their tools. While we work to migrate all machine-readable data files to our cost transparency tool, members will be directed to these other network price comparison tools via HealthView.
Will there be additional costs for the plan?
We realize these are significant legislative changes and expect there to be some corresponding cost increases for employers. These cost adjustments will allow us to continue providing a high level of service you have come to expect from Pinnacle. The new regulations will be taken into consideration when determining our administrative fees at renewal.
We’re here for you.
As always, Pinnacle remains committed to serving you and helping you navigate through these changes as seamlessly as possible. We’ve made it our utmost priority to implement and integrate robust technology solutions that will adhere to these transparency provisions so you can remain in compliance with these regulations. We continue to closely monitor all legislation around the surprise billing and transparency laws and will communicate updates as they become available.