Chapter 3 - Provider Network Participation

Highmark pays claims for services performed by licensed, eligible health care providers. Eligible providers may sign an agreement to participate in one or more of Highmark’s provider networks. Providers who choose not to participate in Highmark’s networks must register with Highmark prior to submitting claimsfor covered services.

As a participant in any of Highmark’s networks, providers agree to provide services to Highmark members according to the terms of their agreement, the regulations that outline their obligations to Highmark members, and any relevant administrative requirements. Although they do not sign an agreement with Highmark, out-of-network providers are required to accurately report services performed and fees charged.

Where the Highmark professional provider networks are utilized to support managed care products,Highmark must credential providers. Providers are initially credentialed prior to network admission and recredentialed at least every three years.

CMS requires Highmark to have the most current information on our network providers and requires ongoing review of all physician information listed in the Provider Directory. It is crucial to your practice to ensure your information is always accurate and up-to-date for the Provider Directory.

Highmark credentials organizational providers (facility and ancillary) in order to ensure they are in good standing with all regulatory and accrediting bodies. Highmark's participation and credentialing requirements derive from internal business decisions as well as the standards set by those agencies.

This unit sets forth provisions of, and procedures and policies resulting from, the Ohio Healthcare Simplification Act (“OHSA”).

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.