Ensuring Quality: Your Role in Timely Medical Record Submission

Highmark is committed to ensuring our members receive the highest quality of care. A critical component of this commitment involves our Quality of Care team's thorough investigation of cases reported by members and various internal Highmark teams. These investigations are essential to determine if care aligns with established clinical standards, while supporting continuous quality improvement across our network.

 For every Quality of Care investigation, timely access to complete medical records is paramount. These records provide the necessary clinical information to accurately assess the care delivered and reach informed decisions. Delays in receiving these vital documents can significantly impede our ability to conduct thorough reviews, prolong case resolution, and ultimately impact our members.

Third-Party Vendors and Medical Records

We understand that providers and facilities often work with third-party vendors for medical record retrieval. It is crucial to establish and maintain efficient processes with these vendors, so that all Highmark requests for medical records are fulfilled promptly. Your cooperation in expediting these requests directly contributes to upholding the quality of care for our shared members.

 Understanding Your Agreement: No Payment for Quality of Care Investigation Records

The submission of medical records for Quality of Care investigations is a fundamental expectation of participating in our networks. As such, Highmark does not reimburse providers or their contracted vendors for medical records submitted in response to Quality of Care investigation requests. Providers are encouraged to review their specific Highmark Professional Provider Agreement and any relevant state-specific regulations to ensure your understanding of this provision.

 Your Partnership in Quality

Your collaboration in providing timely and complete medical records for Quality of Care investigations is invaluable. It enables Highmark to effectively monitor and enhance the quality of services our members receive. By adhering to these requirements, you help us ensure that our members continue to benefit from safe, effective, and high-quality health care.