Unit 1: Introduction
1.1 Manual Purpose and History
The Highmark Provider Manual is designed to be your primary reference guide to Highmark. It contains information, policies, and procedures for all providers participating in Highmark’s provider networks in Delaware, New York, Pennsylvania, and West Virginia, and contiguous counties in their bordering states.The manual combines information for all Highmark service areas to give providers a comprehensive understanding of Highmark’s health insurance programs.
The Highmark Provider Manual, together with other administrative requirements as defined or described in the applicable provider agreement, supplements and is made part of your provider agreement(s). The manual includes, but is not limited to, information such as:
- Services we offer providers and members
- Requirements for participation in our provider networks
- Administrative requirements and guidelines
- Electronic solutions for efficiency and convenience
- Claim submission guidelines for quick and accurate processing
The Highmark Provider Manual is applicable to all provider types who have provider agreements with Highmark, including:
- Physicians and other professional practitioners;
- Hospitals and other facilities; and
- Ancillary and other organizational providers.
Where indicated or as is apparent by the content, certain sections of the manual may not be applicable to all provider types.
Manual History
The online Highmark Provider Manual was first published in 2018, providing one comprehensive resource for all providers participating in Highmark’s provider networks in all service areas in Delaware, New York, Pennsylvania, and West Virginia. This online manual replaces any provider manuals previously used in any of Highmark’s service areas.
Disclaimer
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose. The Highmark Provider Manual is the property of Highmark Inc. and its affiliated health plans, Highmark BCBSD Inc. (Highmark Blue Cross Blue Shield Delaware), Highmark West Virginia Inc. (Highmark Blue Cross Blue Shield West Virginia), Highmark Blue Cross Blue Shield of Western New York, and Highmark Blue Shield of Northeastern New York (individually and collectively referred to herein as “Highmark”). The information, content, and design/organization of the Highmark Provider Manual are maintained by Highmark. Links to external websites referenced in the manual are for the convenience of the user. Such links do not constitute an official endorsement or approval by Highmark or any of its subsidiaries or affiliates with respect to the links’ content.
Highmark complies with all state and federal laws, including laws related to Medicare and our Medicare Advantage products. In cases where administrative requirements (as defined or described in the applicable provider agreement, including but not limited to, Highmark policy, Highmark Medical Policy, and/or the Highmark Provider Manual) conflict with federal or state laws or regulations, or directives of the Centers for Medicare & Medicaid Services (CMS) or other regulators, such laws, regulations, and/or directives shall apply.
Information in the Highmark Provider Manual is subject to change by Highmark. Information in the Highmark Provider Manual is subject to regulatory review and may also be changed at any time in accordance with regulatory requirements. All such changes may be published in provider newsletters, special mailings, and/or forms of online communications such as the Provider Resource Center.
In addition to the Highmark Provider Manual, please check the Provider Resource Center’s home page and its Latest Updates section often for policy and procedure updates. The Highmark Provider Manual is binding upon providers together with other administrative requirements (as defined or described in the applicable provider agreement).
1.1 How to Use this Manual
The Highmark Provider Manual is designed to be your primary reference guide to doing business with Highmark. It contains information specific to procedures required of all Highmark network participating providers — professional, facility, and ancillary — and is intended as a companion to other Highmark provider requirements, publications, and communications.
The Highmark Provider Manual is binding upon providers and may be supplemented or superseded, in whole or in part, by other Highmark guidance and/or requirements furnished or otherwise made available to providers.
Tips for Using This Manual
- Most recent updates: When changes are made to the Highmark Provider Manual, we will communicate those changes on our What’s New page.
- Resources for all Highmark service areas: Because the manual applies to all service areas in Delaware, New York, Pennsylvania, and West Virginia, only the Highmark Blue Shield brand will be referenced.
- The What Is My Service Area? map can be used to help you determine the service area for your location.
- The Quick Reference/Contact Guide contains contact information for all Highmark Provider Service Centers and Highmark Clinical Services.
- Information specific to a service area: For information that does not apply to all service areas, either separate links will be provided or the information will be designated for a specific area by the use of an icon indicating the specific state or states to which the information applies.
State Icons:
- Is the information applicable to facility or professional provider types? Most units of the manual contain information that would be applicable to all provider types. If a unit is specific to professionals or facilities only, it will be noted within the text of the unit.
- Organized by Chapters/Units: The manual is organized by chapters and units. Chapters and their titles are listed in the navigation menu on the left side of the manual webpage. You can click on the arrow to the right of the chapter name to expand the menu, revealing the units and the list of topics covered within that chapter. Click on a unit to access its content.
- To collapse the chapter menu, click on the arrow to the right of the chapter name.
- Search: To make it easier to find answers, there is a search box located at the top of every page. Type a term or phrase into the search box to see where it can be found throughout the manual.
- Intended to be an online resource: Keeping the Highmark Provider Manual electronic allows us to provide you with the most up-to-date information. All revisions to the manual are controlled electronically. Paper copies, screen prints, and all alternate versions noted below are considered uncontrolled and should not be relied upon for any purpose, as they may not be the most recent revision.
Emailing the Manual
To email the manual, click the Share button at the top of the page, and then Copy Link. You can then paste the link in an email.
Printing the Manual
- An entire version of the manual can be printed by clicking the print button at the top right of the page.
Note: Please review the disclaimer in Chapter 1, Unit 1: Introduction (Manual Purpose and History) regarding saved or printed versions of the Highmark Provider Manual.
1.1 About Highmark
In the 1930s, Highmark's predecessor companies were established to help individuals in the communities they served pay for hospital and medical services. Today, that remains our mission — to deliver high quality, accessible, understandable, and affordable experiences, outcomes, and solutions for our customers. It guides our actions throughout Highmark's businesses.
Highmark Inc. was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield and Blue Cross of Western Pennsylvania. Highmark Inc. and its health insurance subsidiaries and affiliates now operate health insurance plans in Delaware, New York, Pennsylvania, and West Virginia that serve millions of members as well as hundreds of thousands of additional Blue Plan members through the BlueCard® program:
- Highmark Blue Cross Blue Shield (PA) provides integrated Blue Cross and Blue Shield coverage throughout the 42 counties of western, north central, and northeastern Pennsylvania.
- Highmark Blue Shield (PA) serves the 21 counties of central Pennsylvania, 5 counties of southeastern Pennsylvania, and the Lehigh Valley.
- Highmark Blue Cross Blue Shield (WV) serves the entire state of West Virginia.
- Highmark Blue Cross Blue Shield (DE) serves the entire state of Delaware.
- Highmark Blue Cross Blue Shield (WNY) serves 8 counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming.
- Highmark Blue Shield (NENY) serves 13 counties: Albany, Clinton, Columbia, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington.
Highmark Health, established in Pittsburgh in 2013, is a national health and wellness organization that employs approximately 40,000 people and serves nearly 50 million individuals in all 50 states and the District of Columbia.
Highmark Health is the parent company of Highmark Inc. and its subsidiaries and affiliates. It is also the parent company for Allegheny Health Network, an integrated health care delivery network, which provides health care delivery, research, medical education, and wellness services.
The company’s diversified businesses provide a spectrum of specialty products such as dental insurance, vision care, and supplemental health programs across the country, including more than 600 Visionworks optical retail stores.
1.1 Highmark Works With Health Care Providers
Highmark understands the tremendous value that physicians, facilities, and other health care professional and organizational providers bring to its organization and to its members. That is why Highmark is constantly striving to make its relationships stronger and better through:
- Enhancing electronic communications and the exchange of data through websites like Availity®;
- Collaborating with providers to implement programs that lead to better medical outcomes for our members; and
- Restructuring our processes to make them easier and more efficient.
At Highmark, physicians and other health care professionals play an important role in the company’s governance and policy making. Independent health care professionals are active in a variety of positions that influence the core of Highmark’s operations — they make up the majority of committees that help resolve claims disputes and promote the delivery of quality medical care to Highmark members.
Health care professionals are also involved at various key junctures during the development of Highmark’s Medical Policy — the guidelines used in our coverage and reimbursement determinations.
Board of Directors
The Board of Directors of Highmark Inc. includes health care professionals (referred to as “Professional Directors”) and representatives from customers and the community (referred to as “Lay Directors”). The Bylaws of the Corporation require that at least fifteen percent (15%) (or as near to that number as can reasonably be achieved) but not more than twenty-five percent (25%) of the Board of Directors be Professional Directors. The business and affairs of the Corporation are managed under the direction of the Board of Directors.
Highmark's Quality Program Committees
As a way for Highmark to promote objective and systematic monitoring, evaluation, and continuous quality improvement, various program committees have been established. Highmark’s Quality Program Committees are made up predominantly of health care professionals and established by Highmark’s Board of Directors. For additional information about these Quality Program Committees, please see the manual’s Chapter 5.6: Quality Management.
1.1 Disclaimers
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
