Guidelines and Tips

PA Act 103 requires insurance companies to reimburse ambulance providers for the response and treatment of a member, even if the member refuses transport to an emergency department. More details are included in the document linked below.

Ambulance Treat No Transport FAQs

The following code sets were revised effective January 1, 2023 to align with Office and Outpatient Evaluation and Management (E/M) Coding Guidelines changes that were effective January 1, 2021:

Providers who are interested in integrating real-time capabilities within their practice management system should discuss this functionality with their software vendors and review Highmark’s EDI website.

Choose the applicable link below to review our EDI transaction and connectivity specifications in the Resources section of the website:

• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml
• New York: https://www.ask-edi.com
• Pennsylvania: https://edi.highmark.com/edi/index.shtml
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml

Highmark Coding Tips is a periodic article that contains billing and coding best practices for professional and facility providers.

Highmark’s claim processing system contains various edits used to appropriately adjudicate claims. One such edit is procedure code combinations. This document lists the procedure codes with applicable component codes.

Procedure Terminology-Based Combinations

This document includes PCP billable service information for providers participating in the First Priority Health (FPH) managed care network in the 13-county Northeastern Region of Pennsylvania.

• PCP Billable Services