MA Tufts Health/Medicaid. After prior authorization approval for out-of-network coverage, how does OON provider obtain letter of agreement with insurance company?

I’m in Massachusetts. My daughter has health insurance through the state. She has medicaid that is provided through Masshealth (the state medicaid insurer) and is managed by Tufts Health Plan.

I’m in the process of fighting to get coverage for my daughters hospital stay for a needed out-of-network/out-of-state procedure. The surgeons fees for the procedure will not be covered but we have to get approved to see the OON provider and hospital in order to get hospital coverage.

Tufts Health Plan has something called “out-of-network benefits at in-network level of benefits”. It’s like a gap exception. After the prior authorization for this was denied due to lack of medical necessity and other things that aren’t really important right now. I wrote and sent in a 35 page appeal proving medical necessity and won.

Now, insurance says that they will cover my daughters procedure/hospital aftercare as in-network or that we’re just approved to see them.. I’m not sure. Coverage all depends on whether or not insurance will agree to pay what they’re asking… right?

Now the next step is for the provider/hospital to get a letter of agreement with the health insurance company to ensure coverage. How would they go about doing this? I gave them the number to provider services and they say they will be in contact with the insurance company.

How is an out-of-network provider/hospital is going to get what they are asking for the procedure/hospital stay? I am not convinced that insurance (especially being medicaid) is going to pay what they are going to ask, but I’m also not sure what they’re going to ask.

I’m just letting insurance and the provider/hospital do their thing and I’ve made them all aware that I am here to answer any questions. Not sure there is anything else I can do.