Unit 4: Benefit Plan Programs
2.4 Baby Blueprints®
Baby Blueprints® is a maternity education and support program available to expectant Highmark members. This free program is designed to help expectant families better understand and enjoy every stage of pregnancy and make more informed care and lifestyle decisions.
Baby Blueprints offers expectant Highmark members educational information on all aspects of pregnancy through online resources during each trimester of pregnancy. Topics include prenatal care, proper use of medications, avoiding alcohol and tobacco, working, travel considerations, nutrition and weight gain, exercise, body changes, and many others. Baby Blueprints will also provide program participants access to individualized support from a nurse Health Coach. Providers are encouraged to promote patient enrollment to reinforce medical care and maternity information so that pregnant women may “have a greater hand in their health.”
Baby Blueprints is available to expectant Highmark members enrolled in a commercial group product, direct pay product, or social mission product.
Baby Blueprints is not available for members enrolled in a Medicare/Medicare Advantage product, Federal Employee Program (FEP), or any self-funded employer groups that have opted out. How members can enroll Enrollment in Baby Blueprints is simple and convenient. Expectant mothers can enroll at no cost over the phone by calling toll free 866-918-5267.
If you have questions about Baby Blueprints, please contact the Provider Service Center.
If members have further questions about Baby Blueprints, please encourage them to call Member Services at the number on their ID card.
2.4 Blues on Call
Highmark has an integrated program, Blues On Call, to attempt to address the total health care needs of the patient rather than focusing on one specific condition. Highmark members may contact Blues On Call 24 hours a day, every day of the year.
The Blues On Call team includes health coaches who provide support over the telephone to help members manage chronic conditions, offer education and support to those facing significant medical decisions and and/or to help members interpret and manage symptoms.
Most Highmark members are automatically eligible to make use of Blues On Call services. No registration is required and the service is free.
Chronic Condition Support
The program content is objective and evidence-based. Information and material is from national sources such as the American Diabetes Association. The scope of chronic condition support through Blues On Call includes:
- Condition-specific standards of care
- Medication adherence
- Specific activities related to medical condition monitoring (weight monitoring, blood sugar monitoring)
- Regular physician visits
- Flu and pneumonia vaccines
Blues On Call does not:
- Address benefit issues
- Address claims issues
- Provide diagnosis or medical advice
Refer a patient to Blues On Call any time he or she needs more information or assistance about a health care topic or if support by a Blues On Call Health Coach would benefit the patient.
Encourage your patient to call the Blues On Call phone line (this number is also located on the back of the member ID card): 888-BLUE-428 (888-258-3428).
2.4 Diabetes Prevention Program
Certain Highmark members have access to a diabetes prevention program as part of their Highmark preventive benefits schedule. Self-funded employer groups may choose to opt out of the program.
The program is available to Highmark members who have coverage under their preventive benefits and meet the program’s eligibility criteria. Eligible members can choose between attending in-person classes in the community or an option with online classes and support.
Note: The program was effective for State of Delaware employees with coverage under a State of Delaware Group Health Insurance Program administered by Highmark Delaware since 2017.
What is the Diabetes Prevention Program?
The Diabetes Prevention Program (DPP) is a structured lifestyle and health behavior change program with the goal of preventing the onset of type 2 diabetes in individuals who are prediabetic. The program is certified by the Centers for Disease Control and Prevention (CDC). The 12-month program includes:
- Choice of an in-person classroom setting or an online/mobile app program
- Sixteen “core” sessions
- Monthly follow-up meetings
The program’s primary goal is to attain at least five percent (5%) average weight loss among participants. According to the CDC, losing five percent of your weight can help prevent diabetes.
Highmark has partnered exclusively with two vendors to deliver the Diabetes Prevention Program to our members. Members can choose the in-person classroom program available at participating YMCA locations or the online program through Retrofit.SM
Program Eligibility Criteria
The vendor of the program option the member chooses, YMCA or Retrofit, will confirm a member’s program eligibility prior to offering program enrollment. Eligible members must be at least 18 years of age and meet criteria of being “prediabetic,” which includes:
- Body Mass Index (BMI) of 25 or greater;
- Fasting blood glucose of 100-125mg/dl; and
- No previous diagnosis of diabetes.
Members may also be Identified as at-risk via the CDC risk screening questionnaire tool available on the YMCA and Retrofit websites as part of the enrollment process.
YMCA’S Classroom Program
The YMCA Diabetes Prevention Program provides a supportive environment where participants work together in a small group to learn about healthier eating and increasing their physical activity in order to reduce their risk for developing diabetes. The program is led by a trained Lifestyle Coach in a classroom setting over a 12-month period, beginning with 16 weekly sessions followed by monthly maintenance. The program is offered at select YMCA locations.
Under the YMCA in-person classroom program, the benefits/services include:
- Member attends structured sessions at an on-site location
- Led by a trained Lifestyle Coach
- Year-long program of 25 sessions
- Food, weight, and activity tracking
- Peer support and accountability
- CDC-approved curriculum
Retrofit's Online/Mobile Program
Retrofit is a leading provider of weight-management and disease-prevention solutions. Retrofit’s online 12-month Diabetes Prevention Program provides personalized coaching from experienced clinicians through online sessions, personalized one-on-one coaching, tracking tools, and peer support.
The benefits/services of the Retrofit program for eligible Highmark members include:
- Welcome kit with wireless scale, activity tracker
- One-on-one expert coaching sessions for nutrition, behavior, exercise physiology
- Expert-led classes
- Expert moderated online community (peer support)
- Online dashboard and mobile app, including food, weight, and activity tracking
- Online proactive and reactive messaging
- Video (live) coaching sessions (telephonic support when preferred)
- Text messaging for “in the moment” personalized coaching
- CDC-approved curriculum
Verify Program Eligibility via Availity®
Providers can verify a member’s coverage for the Diabetes Prevention Program in Availity’s Eligibility and Benefits Inquiry by selecting Additional Benefit Notes.
2.4 Health Promotion Programs
Health promotion and risk reduction is part of the overall health management program. Highmark's Health Management Services (HMS) department offers a variety of condition management, case management, and wellness programs. Services and programs are offered digitally, at the workplace, and telephonically.
Programs are designed to raise member awareness of healthy versus unhealthy habits, make healthy choices, reduce risk of injury, and help members with an acute or chronic condition. The health promotion activities focus on three key areas:
- Health Assessment
- Worksite Health Promotion Programs
- Lifestyle Improvement Programs
Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) are committed to helping our members take an active role in achieving and maintaining good health. That's why we offer health and wellness programs. These programs support your efforts to keep our members healthy by providing them with coverage benefits for health promotion and education services.
Members are more likely to attend health and wellness classes if they receive encouragement from their physicians or other providers and we invite providers to encourage their patients to participate in the programs. We reimburse the health education provider directly, so the member may attend wellness classes without any out-of-pocket expense.
Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) have an extensive network of credentialed providers offering health education classes. Patients do not require a referral or written approval for most approved programs.
Classes are currently offered in the following categories:
- Diabetes education
- Maternal and infant health nutrition
- Physical activity
- Smoking cessation
- Stress management
- Weight management
We also offer programs on topics such as AIDS/HIV, children and adolescent health, arthritis, cancer information, holistic health, substance abuse, senior health, women's health, asthma, heart health, and a variety of support groups.
We encourage our members to take a variety of classes in order to enhance their overall wellness. Programs of similar topics (stress management, diabetes education, nutrition etc.) are limited to one class/program per year with the exception of fitness programs (Pilates, yoga, spinning), which are limited to two programs each year. Maternal and infant health classes are unlimited.
To register, members should contact the health and wellness program provider directly. Members are able to verify program eligibility by calling the customer service number on the back of their identification card.
Digital Resources - All Providers
Digital resources are available to Commercial, Affordable Care Act (ACA), and individual medically insured members, as well as Medicare Advantage and Medigap members. Please see the Reference Guide of Highmark Member Programs for more information.
Worksite Programs
Worksite programs are offered as an optional service to employers wishing to promote a healthy culture among their employees through awareness, education, and activities to encourage engagement.
Services that encourage awareness include on-site biometric screenings. Education services include individual coaching in conjunction with the biometric screening experience, online resources, and newsletter campaigns. Engagement is encouraged through a variety of "Reward" and “Challenge” programs that track participation for incentive purposes.
Case and Disease Management Model
We have transitioned from a primary nurse model to a clinician-driven multidisciplinary team approach allowing us the ability to holistically manage our members and provide them with the right clinical resource at the right time. By leveraging the strengths of a multidisciplinary team, our goals are to meet member needs, improve care coordination, and manage medical expense. This physician-supported team consists of complex case and disease managers, behavioral health specialists, social workers, pharmacists, medical directors, and clinical coordinators.
Comorbidities Addressed
The case and disease managers address comorbidities that many seriously ill individuals face. The Case and Disease Management Model uses motivational interviewing and coaching techniques, and focuses on the whole person. These techniques allow the case and disease managers to address the member's full spectrum of health care issues rather than focusing on a single issue or condition.
Enrollment Time Period
The time period a member is enrolled in a condition management program varies, and is specific to the member's needs. The case and disease managers assist the member in developing care goals whose focus is member self-management. Once these goals are accomplished, the program is closed. Members are encouraged to re-engage with the case and disease managers at any time that their clinical condition requires, or when they simply want the additional support of the case and disease managers to work toward attainment of their goals.
Components of the Case and Disease Management Model
There are three main components in the Case and Disease Management Model:
High Risk Member Outreach
High risk members are coached using motivational interviewing techniques with a focus on self-management. Case and disease managers assess members using questionnaires then, in collaboration with the member, develop goal-directed plans of care. Case and disease managers individualize the length and frequency of each call based on member need or request.
Moderate Risk Member Outreach
Eligible moderate risk members are targeted for Interactive Voice Response (IVR) calls. The goals of these calls are to provide the member with basic information about their condition, to review the member's perception of their self- management and overall health, to provide health tips and reminders specific to their condition, and to offer the member the opportunity to transfer to speak directly to the case and disease managers.
When the member accepts the opportunity to speak to case and disease managers, the member can be enrolled in a condition management program. This enrollment enables the member to have ongoing access to case and disease managers who will assist the member to develop short and long-term self-management goals and to develop strategies for overall health improvement.
The case and disease managers use the member contacts focused on condition management to assist the member with any gaps in care that may be impacting their overall health as well as any screening recommendations that may result in earlier detection of potential health concerns.
Low Risk Member Outreach
Low risk members are targeted for condition-specific mail campaigns. The materials include condition specific topics/questions to discuss with their doctor and a variety of health promotion educational topics such as smoking cessation, nutritional needs, and physical activity recommendations.
2.4 Health Spending Accounts
In today’s health care market, employers and consumers are looking for options to lower their health care costs and have more control over their health care spending. Highmark offers the following health spending account options to respond to those needs:
- Health Savings Accounts (HSAs)
- Health Reimbursement Accounts (HRAs)
- Flexible Spending Accounts (FSAs) including Limited Purpose FSA and Dependent Care FSA
- Commuter Accounts including Parking and Transportation
Health spending accounts help Highmark members to save money to cover their out-of-pocket medical costs, to better manage their health-related expenses, and to be more involved in their health care decisions while also receiving significant tax savings. Members are able to track all of their health care spending online at their secure Highmark member website.
Direct Payment to Provider
If a member’s health spending account is set up for “Direct Payment to Provider” and money is available in the account, you will receive a separate payment (check or Electronic Funds Transfer, or EFT) and notice (known as an Explanation of Payment, or EOP) for claims paid under a member’s spending account.
If the member’s HSA, HRA, or FSA does not have sufficient funds for the entire amount due, you will receive whatever amount is available in the account. You can then bill the member directly for the remaining balance due. As subsequent deposits are made and additional funds become available in the account, the remaining portion of the payment will be distributed to the member.
Explanation of Payment (EOP)
Whenever a full or a partial payment is made to you from a member’s health spending account, you and the member will receive an EOP to document the transaction. Availity-enabled providers will receive their EOPs via the Availity Remittance Viewer function. These are also available in PNC’s ECHO Health platform (DE, PA, and WV only).
This Direct Payment to Provider option from a member’s health spending account does not eliminate your ability to collect patient liability, such as copayments or other outstanding balances, due at the time of service. Highmark provides “Real-Time” tools, accessed via Availity, that help providers determine member responsibility prior to or at the time of services.
- The Patient Cost Estimator function can assist you in estimating the member’s financial responsibility. The estimate will consider any deductible, coinsurance, and/or copayments included in the member’s plan benefits.
- The Claims and Encounters function gives providers the added ability to submit claims for specific health care services and may receive a fully adjudicated response within seconds. This allows providers to determine, at the time of service, the correct amount the member owes.
These real-time estimation and adjudication tools provide immediate responses and give providers the ability to discuss member financial liability with patients when services are scheduled or provided. They also enable providers to collect payment or make payment arrangements for the member’s share of the cost at the time of service. Please note, however, that if you collected payment upfront for member liability, and subsequently receive payment from the member’s health spending account, the refund must be issued directly to the member.
Please note that real-time transactions are accurate at the time of viewing or request. The member’s liability status could change by the time your claim is adjudicated based on claims received but not yet processed, additional services received prior to the adjudication of your claim, or if services rendered are different than those estimated.
For additional information about the Real-Time Tools available via Availity, please see Chapter 1.3: Electronic Solutions - EDI & Availity.
Spending Account Inquiries
For spending account questions or issues in, contact the dedicated Provider Spending Account Information Line:
- Pennsylvania and West Virginia: 800-652-9478
- Delaware: 800-346-6262
Refund Checks for HSA, HRA, and FSA Overpayments
If you receive an overpayment from a member’s HSA, HRA, or FSA, it will be necessary for you to submit this overpayment back to Highmark at the applicable postal address below. Please do not send any overpayments directly to the member. Highmark will ensure that the proper monies are deposited back into the member’s account.
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Pennsylvania & West Virginia |
Delaware |
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Highmark |
Highmark Blue Cross Blue Shield (DE) |
2.4 MyCare Navigator
MyCare Navigator is a telephone-based support service available to Highmark members and their families to help them make informed decisions and get the care that they need. This service is offered as part of our commitment to support health advocacy for our members. The service is free and is available Monday through Friday from 8 a.m. to 8 p.m.
A dedicated myCare Navigator associate can assist members with specific health care issues such as finding a physician or pharmacy, verifying the network status of a physician or pharmacy, making appointments, transferring medical records or prescriptions, and arranging transportation for medical visits.
Highmark members and their families can reach a myCare Navigator health advocate by calling the following toll-free telephone number:
888-BLUE-428 (888-258-3428), Option 2
If you receive inquiries about myCare Navigator from your Highmark patients, you can direct them to this number on the back of their Member ID cards (listed as “Blues On Call”).
Navigator health advocates may be calling your office on behalf of Highmark members or their family members. Please be sure your staff is informed about this service for Highmark members so they are aware of and prepared for these potential incoming calls.
If you have questions about myCare Navigator and the services it offers, please contact Highmark Provider Service.
2.4 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.
