Chapter 57 Mandate – Highmark Billing Guidance for Eligible Members

Highmark is reaching out to certified Chapter 57 behavioral health providers in New York State (NYS) regarding the billing requirements for this new mandate, which applies only to fully insured and Article 47 members.

Key Billing Directives

Member Information

• Eligibility: Providers must verify member eligibility (fully insured vs. Article 47) via Availity Essentials.

Professional Providers

• Professional Group Billing (CMS 1500): Continue current billing practices. 

Include the billing group's NPI and taxonomy code (101YM0800X) in the Billing Provider Loop (Box 33a/b). Important: Leave the Rendering Provider Loop (Line 24J) blank.

• Providers Covered under a Billable Group: If you are not individually credentialed with Highmark BSNENY, you must include the NPI number of your billing provider group and taxonomy code. 
  • This information should be in the Billing Provider Loop on the 837P or in Box 33a (NPI) and Box 33b (Taxonomy, must include ZZ qualifier) on the CMS 1500 claim form. 
  • Billable groups must use taxonomy code 101YM0800X. Additional information regarding CMS 1500 fields can be found at www.nucc.org. 

Facility Providers

• Organizational Setup (UB04 Billing): Providers rendering non-APG (Ambulatory Patient Groups), school-based, or offsite services need to be set up as organizational (UB04) providers. 
  • If you’re not currently credentialed as an organization provider with Highmark, click here. 
• Facility Billing (UB04): A value code 24 and appropriate rate code should be included on every claim. 
  • For members who ARE fully insured or Article 47, bill as you would to NYS, including a rate code and billing with the highest level of specificity, including all diagnoses and modifiers.
  • For members who are NOT fully insured or Article 47, bill as you do today. The procedure codes should be those that are populated from our corporate behavioral health “all other” (AO) fee schedule. Billing codes not on that fee schedule will continue to result in not contracted denials.

We appreciate your patience as we implemented changes to ensure that the Mandate was applied correctly. If you have any claim questions or concerns, use the tools available through Availity.