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.
Unit 1: Introduction to Network Participation
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.
Unit 2: Professional Provider Credentialing
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.
Unit 3: Professional Provider Guidelines
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.
Unit 4: Organizational Provider Participation (Facility/Ancillary)
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.
Unit 5: Ohio Healthcare Simplification Act (PA and WV Only)
This unit sets forth provisions of, and procedures and policies resulting from, the Ohio Healthcare Simplification Act (“OHSA”).
