Latest Updates

Welcome Highmark Blue Shield Providers of Southeastern Pennsylvania

Last Updated: Tuesday, December 10, 2024

Highmark Blue Shield welcomes newly contracted providers in Southeastern Pennsylvania (SEPA). To help acquaint you with working together, we offer tools and resources through our Provider Resource Center (PRC). The Highmark PRC is the central location for helpful information such as:

The Highmark Provider Manual
Forms
Important announcements and updates
Medical, reimbursement, and pharmacy policies
Provider newsletters
Availity Essentials

We encourage you to become familiar with this site and its resources.

Join Our Medicare Advantage Network

If you are eligible to participate in the Highmark SEPA Medicare Advantage (MA) network, you should have received an updated contract or other outreach via email from PIMContracts@highmark.com notifying you that you will be added to the SEPA MA network effective January 1, 2025.

We encourage you to sign and return your contract as soon as possible since you will not be added to the MA network until we receive the signed document.

After January 1, 2025, you must be contracted with us directly to be in-network for all Highmark MA members and avoid disruption for your patients and your practice.

If you did not receive a contract via email, or cannot find the email and would like another contract sent to you, please contact us at SEPAContractingQuestions@highmark.com or 844-945-5525.

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Onboarding Resources

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Click the links below to access information from Highmark staff on how to begin working with us.

General Overview/Onboarding for All Providers - Southeastern PA only
Medical Policy/Utilization Management Overview for Facilities | Video – Southeastern PA only
Medical Policy/Utilization Management Overview for Professional and Ancillary – Southeastern PA only

*Onboarding/training materials for other states/regions available soon.

Video Disclaimer

*By accessing the videos above, I understand that I am leaving the Highmark PRC website and will be redirected to an external website operated by a third-party platform provider. Any use of the third-party platform provider’s website and any information you provide will be subject to and governed by the terms of the third party, including those relating to confidentiality, data privacy, and security.

Click the links below to access information from Highmark staff on how to begin working with us.

Additional reference materials and links can be found on our Provider Orientation and Provider Training pages:

PROVIDER ORIENTATION

PROVIDER TRAINING

PRC Resources

Provider Manual

The Highmark Provider Manual contains information, policies, and procedures for participating medical providers. This manual is designed to be your primary reference guide for working with us.

HIGHMARK PROVIDER MANUAL

Medical Policy Search / Medical Policy Update

Highmark’s medical policy guidelines are available through the Medical Policy Search. You can search by keyword, procedure code, or medical policy number.

MEDICAL POLICY SEARCH

The link above will take you to the Pennsylvania Medical Policy Search website. To view another state, please navigate to Policies & Programs then Medical Policies in the top website menu.

Medical Policy Update is a monthly newsletter that provides information about upcoming medical policy and claims administration updates.

MEDICAL POLICY UPDATE

You can receive these updates by signing up for our mailing list.

JOIN OUR MAILING LIST

Pharmacy Policy Search / Formulary Updates

Pharmacy policies are intended to reflect Highmark's reimbursement and coverage guidelines. You can access them through the Pharmacy Policy Search on this site (link below). You can search by keyword or one of the following categories:

Formulary
Managed Rx Coverage
Prior Authorization
Quantity Level Limits
Step Therapy

PHARMACY POLICY SEARCH

The Highmark Drug Formulary is a list of FDA-approved prescription drug medications reviewed by our Pharmacy and Therapeutics (P&T) Committee. The formularies and pharmaceutical management procedures are updated on a bi-monthly basis. Additional information on drug formularies and updates can be found on the Formulary Information page.

FORMULARY INFORMATION

Procedures Requiring Prior Authorization

Highmark requires authorization of certain services, procedures, and/or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) prior to performing the procedure or service. You can review which services and procedures require authorization by visiting our Authorization Guidance page.

AUTHORIZATION GUIDANCE

Reimbursement Policy

Highmark Blue Shield issues new or updated reimbursement policies regularly. You can check the Reimbursement Policy page under Claims & Authorization, for policy updates.

REIMBURSEMENT POLICIES

You can visit the Provider News page on the PRC as well as subscribe to our mailing list to get Provider News updates and announcements emailed to you on a monthly basis.

PROVIDER NEWS

JOIN OUR MAILING LIST

Provider Communications

Highmark is committed to keeping you informed by providing timely and pertinent information about our policies and programs.

Provider News is Highmark’s monthly newsletter – posted to the PRC and sent via email – for our network health care professionals, facilities, and their office staff. Provider News contains valuable news, information, tips, and reminders.

PROVIDER NEWS

Our email notification feature brings the latest Provider News and other Highmark information directly to your inbox ensuring you don’t miss important updates and changes.

JOIN OUR MAILING LIST

Special Bulletins are posted to the main page of the PRC for easy access. We also post proprietary messages in our provider portal which can be accessed by logging into your provider account.

SPECIAL BULLETINS

Availity

Availity^® is a multi-payer platform that supports payer-provider transactions necessary to manage care for members. Providers in Southeastern Pennsylvania will use Availity to:

Verify patient eligibility and benefits
Check claim status
Submit prior authorization requests
Access Highmark-specific resources through a dedicated payer space

You may already use Availity to interact with other payers. If you are already registered with Availity, you do not need to re-register.

If you are not registered with Availity, you can find information by going to the Register and Get Started with Availity Essentials webpage.

Additional information can be found under Latest Updates - Availity section.

AVAILITY

*By accessing this video, I understand that I am leaving the Highmark PRC website and will be redirected to an external website operated by a third-party platform provider. Any use of the third-party platform provider’s website and any information you provide will be subject to and governed by the terms of the third party, including those relating to confidentiality, data privacy, and security.