PBGH just recently sent out a client alert regarding UPMC/Highmark Continuity of Care Settlement as follows:  UPMC and Highmark have announced a settlement agreement that addresses the Consent Decrees’ Continuity of Care provision. This settlement will govern continuity of care beginning January 1, 2016 until the end of the Consent Decrees on June 30, 2019.

The settlement agreement provisions include:

  • The need for continuing course of treatment will be determined by the patient’s physician in consultation with the patient
  • In-network access is available for patients who were in a continuing course of treatment for a chronic or persistent condition in 2013, 2014, or 2015
  • All services reasonably related to treatment will be covered at in-network rates
  • UPMC will identify “continuity of care” claims for Highmark and provide appropriate documentation as requested by Highmark. If Highmark does not receive the information received within 10 days, the claim may be deemed out-of-network
  • Clinical review and claims submission to the Department of Health where there is an in-network claims dispute