Unit 1: Network Participation Overview
3.1 Introduction to Network Participation
3.1 PROMISe Enrollment Required for Pennsylvania CHIP
3.1 Electronic Transaction Requirements
3.1 Select DME Network (PA Only)
3.1 Directing Care to Network Providers
3.1 How to Register With Highmark
3.1 How to Become a Participating Provider (PA Only)
3.1 Participation in Highmark Credentialed Networks
3.1 Provider Tax Identification Numbers
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 claims for 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.
All providers who submit claims to Highmark must obtain an individual National Provider Identifier (NPI) number. Highmark will only make payments for eligible services rendered by a provider with a valid NPI. To learn more about obtaining an NPI, please see the section in this unit titled National Provider Identifier (NPI).
Non-Discrimination Policy
In selecting and credentialing providers for the associate networks, Highmark does not discriminate in terms of participation or reimbursement against any health care professional who is acting within the scope of their license or certification. In addition, Highmark does not discriminate against professionals who serve high-risk populations or who specialize in the treatment of costly conditions. If Highmark declines to include a provider in its networks, Highmark will furnish written notice of the reason for its decision to the affected provider.
Compliance with the Mental Health Parity and Addiction Equity Act
In compliance with the Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”), Highmark applies the same network admission and provider credentialing standards to all providers in comparable manner regardless of whether the provider renders medical services, behavioral health services, or substance abuse treatment services.
Eligible Organizational Providers (Facility and Ancillary)
Highmark holds contracts with organizational providers (facility and ancillary) and credentials them to ensure they are in good standing with all regulatory and accrediting bodies.
- Eligible facility type providers include, but are not limited to, acute care hospitals, psychiatric facilities, substance abuse treatment centers, skilled nursing facilities, ambulatory surgical centers, hospice, and home health.
- Eligible ancillary providers include freestanding and facility-based providers including, but not limited to, independent laboratories, durable medical equipment, home infusion, and ambulance.
For more information specifically on organizational provider participation, please see the manual’s Chapter 3 Unit 4: Organizational Provider Participation.
Who is an Eligible Professional Provider?
Eligible professional providers include:
- Certain certified registered nurses
- Doctors of Chiropractic (DC)
- Doctors of Dentistry (DDS/DMD)
- Doctors of Medicine (MD)
- Doctors of Optometry (OD)
- Doctors of Osteopathy (DO)
- Doctors of Podiatry (DPM)
- Licensed audiologist
- Licensed clinical social workers
- Licensed dietitian – nutritionist
- Licensed marriage and family therapists
- Licensed occupational therapists
- Licensed physical therapist
- Licensed professional counselors
- Licensed psychologist
- Licensed speech-language pathologist
- Nurse midwives
Additional Providers Eligible in West Virginia
Highmark Blue Cross Blue Shield (WV) also contracts with the following provider types for networks and/or programs as indicated:
- Acupuncturists – for Federal Employee Program (FEP) members and Medicare Advantage members only
- Massage Therapists – for commercial networks only
- Certain diabetic educators – for all provider networks*
- Licensed Physician Assistants – for all provider networks*
*Including Medicare Advantage
Additional Providers Eligible in Delaware
Highmark Blue Cross Blue Shield (DE) also contracts licensed Physician Assistants in all networks.
Additional Providers Eligible in New York
Licensed Mental Health Counselors (LMHC) are eligible in all commercial networks.
Effective January 1, 2024, LMHCs are also eligible in Medicaid and Medicare Advantage networks.
Effective January 1, 2024, Psychoanalysts with a Psychoanalyst license are eligible in all commercial networks.
Acupuncturists
Practitioners who are not eligible to contract with Highmark to participate in Highmark’s networks in Delaware and Pennsylvania may be eligible to provide services for certain government programs only (e.g., FEP and Medicare Advantage).
Although acupuncturists are not eligible to contract with Highmark for our commercial networks in Delaware and Pennsylvania, they are fully credentialed and contracted to provide services to FEP and Medicare Advantage members only.
Acupuncturists
Acupuncturists in New York are eligible for Medicare Advantage, FEP, and commercial networks.
Physician Assistants
Physician Assistants (PA-Cs) in Pennsylvania and New York are not eligible to participate in Highmark’s commercial or Medicare Advantage networks as independent practitioners; however, PA-Cs can bill as a rendering provider once they enumerate within Highmark’s systems.
PA-Cs in West Virginia and Delaware can independently bill if they have met Highmark’s credentialing requirements. Providers who have not met Highmark’s credentialing requirements are not eligible to participate in Highmark’s commercial or Medicare Advantage networks as independent practitioners; however, PA-Cs can bill as a rendering provider once they enumerate within Highmark’s systems.
For more information on Physician Assistants billing as a rendering provider, review Reimbursement Policy 010: “Incident To” Billing.
Practitioners Who May Serve as PCPs
A physician (MD or DO) who is a family practitioner, general practitioner, internal medicine practitioner, Geriatricians, Adolescent Medicine, Obstetrics/Gynecologists, or pediatrician is entitled to participate as a primary care physician (PCP). The physician must complete the credentialing process.
In addition, certified registered nurse practitioners (CRNPs) have the opportunity to offer their clinical expertise as a primary care CRNP to Highmark members. Qualified CRNPs must complete a credentialing application and meet credentialing requirements to receive designation as a primary care CRNP with Highmark. CRNPs cannot be dual credentialed and serve as both a CRNP specialist and a PCP within the same group practice. However, a CRNP can be dual credentialed for different group practices, serving as a CRNP specialist in one group and as a PCP in another group practice.
In West Virginia and Delaware only, physician assistants (PAs) may also participate as PCPs.
Practitioner Availability Monitoring
Since Highmark requires members to utilize a designated practitioner network, Highmark must ensure that there are adequate numbers and geographic distribution of primary care, behavioral health, and specialty care practitioners to meet member needs. Highmark monitors practitioner availability annually against its standards and initiates action, as needed, to improve member access to covered services.
Practitioner availability monitoring is completed for primary care practitioners, high-volume specialty care practitioners, and behavioral health practitioner types. All behavioral health practitioner types (not just high-volume types) are assessed on an annual basis.
General Conditions of Participation
In order to participate in Highmark’s networks, a provider must:
- Execute the appropriate network participation agreement(s), which include the terms of payment, and complete fully any required application or information forms;
- Abide by the terms and conditions of such agreement(s), including any amendments;
- Satisfy and remain in compliance with applicable Highmark credentialing and recredentialing standards;
- Cooperate and comply with Highmark’s health services management programs, including but not limited to: precertification, prior authorization, care and case management, disease management, clinical quality improvement, and other programs and initiatives that may be adopted;
- Provide timely written responses to complaints or clinical quality issues upon request from Highmark;
- Follow Highmark’s appeals processes and other dispute resolution mechanisms; and
- Adhere to Highmark’s billing, claims submission, and other administrative guidelines and requirements, including this Highmark Provider Manual.
Open/Closed Networks
Highmark accepts applications in any of its networks, with only a limited area closed to new practitioners of specific provider types. Highmark reserves the right, however, to close one or more of its networks to specific types of providers or to additional service locations if:
- Highmark determines that it has contracted with a sufficient number and distribution of providers to serve its members adequately; or
- Highmark determines that closing the network would otherwise be in the best interests of its members, the company, and network providers.
If Highmark elects in the future to close a network, notice of such policy will be communicated.
Mutual Roles and Obligations for Network Participating Providers and Highmark
As a participant in any of Highmark’s networks, providers agree to a set of regulations that outline their obligations to Highmark members. Highmark has obligations to its network participants as well. The agreements and regulations that providers execute when joining the network contain the mutual obligations.
Key contractual provisions include:
- Network providers will accept the network allowance as payment-in-full for covered services, less any applicable copayments, deductibles, and/or coinsurance.
- Highmark will make payment directly to network providers and will notify members of any responsibility they may have (such as non-covered services, coinsurance, and/or deductibles).
- Network providers will handle basic claims filing paperwork for the member.
- Highmark will encourage members to obtain health care services from network providers which could increase the provider’s patient base.
- Network providers will recommend their patients see other network providers when necessary.
- Providers participating in any of Highmark’s professional provider networks are eligible to become actively involved with Highmark as corporate professional members and as members of the company’s various professional committees and advisory councils.
Equal Access and Non-Discrimination in Treatment of Members
In addition to requirements contained in your provider agreement and in any other applicable administrative requirements, network providers agree to requirements of equal access and non-discrimination of Highmark members within this manual. Complaints will be investigated as appropriate and referred to the Credentialing Committee for appropriate action.
Providers will give members equal access at all times to provider services. Providers agree not to discriminate in the treatment of Highmark members, or in the quality of services delivered, on the basis of place of residence, health status, race, color, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment. Further, providers shall not deny, limit, discriminate or condition the furnishing of provider services to members based on their known or believed relationship or association with an individual or individuals of a particular race, color, national origin, sex, age, or disability.
Meeting Cultural and Linguistic Needs
Network providers must ensure that services, both clinical and non-clinical, can meet the cultural and linguistic needs of all members, including those with limited English proficiency, disabilities, reading skills, diverse cultural and ethnic backgrounds, sexual orientation, and the homeless; and are responsive to member needs and preferences.
Highmark may be able to assist a provider to locate translator or interpreter services for members who are non-English speaking or hearing impaired. The provider or member should call the Highmark Member Service telephone number on the back of the member’s ID card.
Non-Retaliation for Exercise of Rights and Remedies
Providers are encouraged to become knowledgeable of the rights and remedies available to them under their agreement(s) with Highmark, this Highmark Provider Manual, and other administrative policies and procedures.
It is our policy to treat providers courteously, professionally, and fairly in all circumstances. Providers can be assured that they will not be subject to discriminatory treatment or retaliation in any form of exercising rights and remedies afforded them pursuant to their agreements with Highmark.
The Pennsylvania Department of Human Services (DHS) implemented the Affordable Care Act (ACA) Provider Enrollment and Screening provisions that require all providers who render, order, refer, or prescribe items or services to Children’s Health Insurance Program (CHIP) enrollees to have a valid PROMISe™ ID.
Providers who provide services to Highmark Healthy Kids (CHIP) enrollees must complete a Provider Reimbursement and Operations Management Information System (PROMISe) enrollment application for their provider type for each service location where they see CHIP enrollees. Once enrolled, the provider is issued a PROMISe ID, which is required to provide services to CHIP enrollees and receive reimbursement.
PROMISe ID Enrollment Requirements
PROMISe enrollment is required to provide services to Highmark Healthy Kids (CHIP) enrollees and receive payment for claims. The enrollment requirements apply to all providers who provide services to CHIP enrollees covered under the Pennsylvania CHIP program. The Pennsylvania Office of CHIP requires every provider servicing CHIP enrollees to have a PROMISe ID assignment for each service location and for each provider NPI (includes practitioner, group, vendor, and billing NPI).
To enroll, you must complete an enrollment application appropriate for your provider type and for each service location. A service location is defined as a physical street address where a practitioner: 1) maintains an office; 2) holds office hours/sets appointments; and 3) renders services. Once enrolled, you will receive a 13-digit PROMISe ID unique to each service location.
If you are already enrolled in PROMISe ID for the Pennsylvania Medical Assistance Program (also called “Medicaid”), you do not need to enroll again for CHIP. However, if you are enrolled with another state’s Medicaid or CHIP program or are enrolled in Medicare, you must enroll with Pennsylvania’s DHS to service CHIP enrollees in Pennsylvania.
Note: Most providers are not required to pay the application fee, which typically applies to larger facilities.
Important! Avoid Claim Denials
Highmark is required to deny claims if we are unable to match the provider’s NPI reported on the claim to a PROMISe enrollment record for the service location where the services were performed. To avoid claim denials, ensure that you have enrolled and received a PROMISe ID for all service locations prior to that date. In addition, always report any changes to your practice in a timely manner to avoid any future claim denials.
Service Location Enrollment Guidelines
The following explains how specific types of providers are to enroll service locations.
Individual Providers
Individual providers must enroll every service location where they provide services to Highmark Healthy Kids (CHIP) enrollees, except as noted below. This results in each service location having its own unique service location number. Providers who work at multiple locations or offices must enroll each location at which they provide services.
Institutional Locations
Individual providers who have clinical privileges at an institutional location do not need to enroll these places of service. The institutional locations are those using the following Place of Service (POS) codes:
|
POS Code |
Place of Service Name |
|---|---|
|
21 |
Inpatient Hospital |
|
22 |
On Campus — Outpatient Hospital |
|
24 |
Ambulatory Surgical Center |
|
31 |
Skilled Nursing Facility |
|
32 |
Nursing Facility |
However, if the individual provider is employed by the institution and the only place they provide services is the institutional location, the individual provider must enroll at the institutional location.
Radiologists and Anesthesiologists
Individual providers enrolled with the following provider types and specialties, who may have enrolled previously at only one service location, must enroll at every service location where they provide services, unless they are providing services at an institutional location as described above.
|
Provider Type |
Specialty |
|
|---|---|---|
|
Radiologist |
31 |
341 |
|
Anesthesiologist |
31 |
311 |
|
Certified Registered Nurse Anesthetist (CRNA) |
32 |
320 |
Provider Groups
Provider groups must enroll all of their service locations and receive a separate service location number for each location. Additionally, each group member must enroll as an individual provider at each service location where the individual provider practices.
Highmark Healthy Kids (CHIP) Promise ID Enrollment Application
Providers can complete a PROMISe ID application to enroll in Highmark Healthy Kids (CHIP) and/or Pennsylvania Medical Assistance. If completing an application for CHIP only, you would not be enrolled as a Medical Assistance provider and you would not be required to service Pennsylvania Medical Assistance beneficiaries.
CHIP PROMISe ID enrollment information and applications, both electronic and printable PDF versions, are available on the DHS website.
How the PROMISe ID is Determined
The PROMISe ID is a 13-digit number based on the Federal Tax ID Number, provider type and specialty (s), and the physical location where services are provided. The first nine digits are assigned for a given Federal Employer Identification Number (FEIN) or Social Security number (SSN). The last four numbers reflect a 4-digit Service Location Code that is based on provider type, specialty, and physical location. Click on the link to access the list of provider types/specialties that are reflected in Service Location Codes.
Your PROMISEe ID is Automatically Added to Highmark’s Provider File
Highmark receives a listing of the PROMISe IDs for Highmark-affiliated providers electronically from the Pennsylvania Department of Human Services, and these IDs are automatically uploaded into Highmark’s Provider Information Management system for each individual provider.
Reporting Changes
Any changes to your practice must be reported to DHS in a timely manner. Information and forms for various types of changes are available on the DHS website.
Revalidation
All providers must revalidate their PROMISe enrollment for each service location every five years. Providers should log into PROMISe to check the revalidation dates of each service location and submit revalidation applications at least 60 days prior to the revalidation dates. Enrollment (revalidation) applications may be found here.
Frequently Asked Questions
We have developed frequently asked questions to help you understand more about PROMISe ID enrollment requirements and the importance of enrolling in order to receive reimbursement for the services you provide to Highmark Healthy Kids (CHIP) enrollees.
For More Information
For more information about the CHIP program in Pennsylvania, please see the Highmark Provider Manual’s Chapter 2 Unit 3: Other Government Programs.
Providers participating in Highmark’s provider networks must comply with the terms and conditions of their provider agreement(s) and meet acceptable standards for quality of clinical care, resource utilization, and administrative compliance to ensure that the networks operate in an effective and efficient manner. This also ensures that members receive high quality, medically appropriate, and cost-effective care.
Providers who are not compliant are subject to the network corrective action policy providing for corrective action, sanctioning, suspension, and termination of providers arising from non-compliance with contractual obligations or failure to meet acceptable standards of clinical care, resource utilization, and/or administrative compliance.
Categories of Non-Compliance
Non-compliance can be divided into three categories:
- Quality-of-care concerns
- Unacceptable resource utilization
- Administrative non-compliance
Quality-of-Care Concerns
A quality-of-care concern arises when an episode of care deviates from accepted medical standards. The occurrence of an adverse outcome does not, in and of itself, indicate a breach of accepted medical standards and/or warrant action.
Examples of Quality-of-Care Concerns
Examples of quality-of-care concerns include, but are not limited to:
- Actions or omissions that result or may result in an adverse effect on a patient’s well-being
- Delayed services/referrals
- Missed diagnoses
- Medication errors
- Delayed diagnosis/treatment
- Unexpected operative complications
- Invasive procedure complications
- Inappropriate procedures
- Unanticipated, unexplainable death
- Actions requiring a report to the National Practitioner Data Bank (NPDB) or other adverse actions
Unacceptable Resource Utilization
Unacceptable resource utilization is defined as a pattern of utilization that is at variance with recognized standards of clinical practice or with specialty-specific aggregated data.
Examples of Unacceptable Resource Utilization
Examples of patterns of unacceptable resource utilization include but are not limited to:
- Inappropriate or unnecessary admissions
- Inappropriate utilization of emergency services
- Inappropriate or unnecessary inpatient hospital stay days
- Patterns of inappropriate utilization of outpatient surgery
- Patterns of inappropriate PCP encounters per member per year
- Patterns of inappropriate utilization of referrals
- Under-utilization (i.e., withholding) of necessary and appropriate medical services
Administrative Non-Compliance
Administrative non-compliance is defined as behavior that does not comply with applicable laws, regulations, or Highmark policies or procedures, or that is detrimental to the successful functioning of Highmark as a health plan or to its members’ rights or benefits under their plan.
Examples of Administrative Non-Compliance
Examples of administrative non-compliance include but are not limited to:
- Direct or unauthorized billing for services
- Balance billing a member for services
- Failure to cooperate/comply with Highmark’s administrative quality improvement, utilization review, credentialing, member service, reimbursement, and other procedures
- Conduct that is unprofessional toward members, family members, and/or staff of Highmark
- Failure to comply with any contractual obligation
- Failure to comply with policies and procedures of Highmark
- Failure to comply with or violation of state or federal laws or regulations
Use of Information and Data for Quality Improvement and Transparency and Compliance Requirements
Providers acknowledge and will cooperate with Highmark's quality improvement and transparency programs and initiatives, which include, but are not limited to, programs developed to support Highmark’s member and provider initiatives, and satisfy the compliance requirements of the National Committee for Quality Assurance (NCQA), other accreditation entities, and any applicable regulatory body (collectively, “Quality Initiatives”).
In connection with Quality Initiatives, Highmark may use the Provider Data for such purposes, including but not limited, as follows:
- Utilize, publish, disclose, and display any information and data related directly or indirectly to the Provider’s delivery of health care services, such as, but not limited to, performance or practice data, information relating to Provider’s costs, charges, payment rates and quality, utilization, outcome and other data (“Provider Data”);
- Disclose the Provider Data to Highmark’s contracted vendors and agents to assist in the review, analysis, and reporting of the Provider Data;
- Report the Provider Data to other providers to assist such providers in the management of care costs, quality outcomes, and other efficiencies;
- Report the Provider Data to Members and customers (including third parties who supply information and analysis services to group customers); and
- Use the Provider Data to support Provider’s participation in certain benefit value levels (such as network tiers).
Providers acknowledge and agree that any Provider Data is proprietary to Highmark, a highly confidential trade secret of Highmark, and is entitled to protection as such. In the event that a provider receives any Provider Data (which may be the provider’s own Provider Data or the Provider Data of a provider other than the provider), the provider agrees to maintain the Provider Data as confidential and to use it for the purpose or purposes for which the Provider Data was provided by Highmark or its contractor or agent and agrees to not publish or publicly share the Provider Data, except as expressly permitted by Highmark in writing.
Without limiting the foregoing, any provisions in the provider’s participating agreement or Administrative Requirements that address the confidentiality of information and data, such as the Provider Data, shall remain in full force and effect and such provisions shall govern the Provider Data in addition to this section of Chapter 3.1 of the Highmark Provider Manual.
In support of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, Highmark has taken steps to eliminate paper transactions with our contracted providers. Because of the inherent speed and cost-effectiveness, electronic and online communications are integral in today’s business world and Highmark requires that all network providers participate in electronic programs sponsored or utilized by Highmark now or in the future.
Enrollment in Availity, EFT, & Paperless EOBs/Remittances Required for All Participating Providers
All Highmark network participating providers are required to enroll in Availity®, Electronic Funds Transfer (EFT), and paperless Explanation of Benefits (EOB) statements and Remittance Advices. All new assignment accounts must sign up for Availity and also enroll in EFT and paperless EOBs/remittances.
Availity is an easy online solution linking physician offices and facilities with Highmark and other health plans. Availity integrates all insurer-provider transactions into one system (e.g., eligibility and benefit inquiries, claim status inquiries, claim submission, authorization requests, etc.). This service is available at no cost to Highmark network participating providers.
Participating providers are also required to enroll to receive electronic funds transfers and paperless EOB statements/ remittances.
- EFT is a secure process that directs Highmark claim payments to the provider’s checking or savings account as directed by your office. Payments are typically in the designated bank account by Wednesday of each week. For Delaware, Pennsylvania, and West Virginia providers, this information is also available for viewing within PNC’s Healthcare’s ECHO Health platform.
- Paperless EOB statements and remittances reduce the amount of paper flowing into the provider’s office. They are available for viewing on Monday morning via Availity – which is two days earlier than receiving them by mail. For Delaware, Pennsylvania, and West Virginia providers, this information is also available for viewing within PNC’s Healthcare’s ECHO Health platform.
How to Sign Up for Availity
Providers who are not currently registered to use Availity should go to the Register and Get Started with Availity Essentials webpage.
Enrolling in EFT and Paperless EOBs
Claims payments are generated by PNC-ECHO Health Trust. Electronic Remittance Advices (ERAs) are distributed using the ECHO Payer ID 58379. Providers may elect to receive EFT only or 835/EFT through the ECHO Health platform. To sign-up to receive EFT on the ECHO Health platform, visit their EFT/ERA enrollment page.
Virtual Credit Cards: Providers who have not registered to accept payments electronically will receive virtual credit card payments with their EOBs. Offices opted in to virtual credit cards (VCC) will receive notification for each payment via mail or fax, which will include a unique virtual credit card number and instructions for processing. Providers may opt out of VCC by visiting/calling ECHO Health at 800-890-4124.
Additional payment options: ECHO also offers payments via Medical Payment Exchange (delivers payments and EOBs electronically and gives providers the option to print a check at no cost, receive a virtual card payment, or enroll for EFT) or paper check. Explore more details about these options on ECHO Health’s platform.
Once providers are enrolled and start receiving EFT payments, providers will no longer receive paper EOB statements or remittances. Providers will still be able to view the claims status and a copy of the EOB through Highmark’s provider portal. However, providers will need to visit ECHO’s provider platform to manage/change payment information.
Enrolling in EFT and Paperless EOBs
After becoming Availity-enabled, providers must also enroll in electronic funds transfer (EFT) and paperless Explanation of Benefits (EOB) statements. To do this, please contact the Provider Service Center.
Health Information Exchange Programs
Network providers are also required to participate in any Highmark, Highmark-sponsored, and/or Highmark-designated state or community-sponsored health information exchange program, which supports and/or facilitates the availability and exchange of claims-based information and clinical information for the treatment and ongoing management of Highmark members and/or other patients of network providers.
Any requirements relating to participation in such health information exchange program shall be provided through Highmark communications and/or administrative requirements in advance of such participation requirement and shall be binding on network providers and Highmark.
Overview of Pennsylvania Networks
This section provides brief descriptions of Highmark’s professional provider networks in the state of Pennsylvania and contiguous counties.
Commercial networks in Pennsylvania include:
- Participating Provider Network
- Premier Blue Shield statewide provider network
- Keystone Health Plan West (KHPW) managed care network (Western Region only)
- Community Blue select network
Medicare Advantage networks in Pennsylvania:
- Freedom Blue PPO
- Community Blue Medicare PPO/Plus PPO
- Medicare Advantage HMO (Western Region only)
- Community Blue Medicare HMO
Participating Provider Network
Highmark has agreements with thousands of Participating Providers representing every major specialty. Any eligible professional provider licensed to practice in Pennsylvania may apply for participating status by completing the Participating Provider Agreement With Highmark Blue Shield.
This is not a credentialed network – a professional provider’s admission to the network is based solely on Pennsylvania licensure and the execution of a Participating Provider Agreement. This network services our traditional Highmark Blue Shield programs, including traditional BlueCard® as well as BlueCard Point of Service (POS) and Health Maintenance Organization (HMO) programs.
Premier Blue Shield Network
The Premier Blue Shield Network is Highmark’s statewide selectively contracted preferred provider network in Pennsylvania. Any eligible facility and professional provider licensed to practice medicine in Pennsylvania may apply for the Premier Blue Shield network. You must meet the network’s credentialing criteria to be accepted into the network.
Because Premier Blue Shield supports managed care products, Highmark must ensure the network complies with the regulations of the Pennsylvania Department of Health governing Managed Care Organizations (28 PA Code, Chapter 9). These regulations require that we ensure network providers meet certain standards. As a result, Highmark staff conducts site visits and medical record reviews of primary care practitioners, obstetricians/gynecologists, high-volume behavioral health provider offices, and facilities.
This network supports a variety of coverage programs. Premier Blue Shield also supports the BlueCard Preferred Provider Organization (PPO) programs in Pennsylvania’s Central Region and is used by other carriers who have an arrangement with Highmark. The Federal Employee Program (FEP) is the largest customer that utilizes this network in the Central, Eastern, and Northeastern Regions of Pennsylvania.
Western Region KHPW Managed Care Network
The Keystone Health Plan West (KHPW) managed care network in the 29-county Western Region of Pennsylvania supports the managed care products in Highmark’s Western Region only. These include health maintenance organization (HMO) coverage plans and the Children’s Health Insurance Program (CHIP). This network also supports the Federal Employee Program (FEP) in the western part of Pennsylvania. In addition, this network supports BlueCard PPO programs in the 29-county Western Region.
The network is comprised of highly qualified PCPs, leading medical specialists, and facilities offering a broad range of care. Eligible licensed professional providers practicing medicine in Highmark’s Western Region may apply for participation in the network. Professional providers must meet credentialing criteria and sign a Highmark Choice Company Professional Provider Agreement.
Since it supports Highmark’s managed care products in the Western Region, this network must also comply with Pennsylvania Department of Health regulations governing managed care organizations. Therefore, Highmark also conducts site visits and medical record reviews of network participating providers’ offices and facilities to ensure they meet necessary standards.
Highmark Healthy Kids (CHIP)
The PA CHIP Network supports the CHIP health maintenance organization (HMO) product in all 62 counties of Pennsylvania’s service areas. The network is comprised of providers who have enrolled in PROMISe ID with the Pennsylvania Department of Human services.
Community Blue Commercial Network
The Community Blue networks, located in Pennsylvania’s Western and Central Regions, are select networks that support the commercial Community Blue PPO and EPO products. These products were designed to provide an affordable choice for customers seeking lower cost coverage while still being able to receive high quality, cost-efficient care from highly reputable health care providers.
The Community Blue hospital networks include community and world-renowned hospitals while the physician network includes primary care physicians and specialists who are also part of the larger managed care networks in each region.
Members can locate participating Community Blue providers by using the applicable regional Provider Directory accessible on MyHighmark.com by selecting Find Doctors and RX.
First Priority Health Network
The First Priority Health managed care network in the 13-county Northeastern Region of Pennsylvania supports the health maintenance organization (HMO) products in this service area. This includes, but is not limited to, BlueCare® HMO, BlueCare® HMO Plus, and the Children’s Health Insurance Program (CHIP).
The First Priority Health network of professional providers and facilities spans throughout the 13-county service area and includes several hospitals and their participating physicians in contiguous counties in Pennsylvania, New Jersey, and New York. To be included in the network, practitioners and facilities must maintain high-quality standards and meet strict credentialing criteria.
Medicare Advantage Networks
The networks are the cornerstones of the Medicare Advantage HMO and PPO programs in Pennsylvania. Medicare Advantage HMO members are required to obtain services from providers participating in the applicable Medicare Advantage network – except for urgent or emergent care. Members with Medicare Advantage PPO plans have both in-network and out-of-network benefit options.
The Medicare Advantage preferred provider network supporting Freedom Blue PPO spans a 62-county service area, including all Pennsylvania counties except Bucks, Chester, Delaware, Montgomery, and Philadelphia in the Eastern Region.
The Medicare Advantage network supporting Security Blue HMO members (in Pennsylvania’s Western Region only) includes an expansive network of professional and facility providers in the 28-county service area.
Community Blue Medicare HMO and PPO networks are select, high-value networks in select counties throughout Highmark’s regions supporting the Community Blue Medicare products. Community Blue Medicare PPO has a broader network of providers than Community Blue Medicare HMO, while the Community Blue Medicare Plus PPO network is limited to Clinton, Lycoming, Sullivan, and Tioga counties with exclusive access to Geisinger Danville facilities and doctors.
To be included in a Medicare Advantage provider network, a provider must participate in the Medicare program itself. For more information on Medicare Advantage, please visit Chapter 2 Unit 2: Medicare Advantage Products & Programs.
Note: The Community Blue Medicare HMO network differs from the network associated with the commercial Community Blue products.
ACA Select Network
The ACA Select Network supports Highmark Affordable Care Act (ACA) my Direct Blue HMO and EPO products that are available in certain counties in Pennsylvania. The ACA Select Network is comprised of select local physicians and hospitals that provide quality outcomes at an affordable cost for my Direct Blue ACA members in those counties.
Physician practices employed by a hospital or health system in the ACA Select Network will also participate in the network. Network participating providers can be located by using the online Highmark Provider Directory.
Note: Highmark continues to offer ACA PPO plans in most regions that use the broader networks, as applicable.
Delaware
The Delaware Provider Network spans all three counties in the state of Delaware and also contiguous counties of neighboring states. Highmark Blue Cross Blue Shield (DE) has participating provider contracts with more than 90 percent of Delaware’s physicians and health care providers and includes all hospitals in Delaware.
As the leading health benefits company in the state, Highmark Delaware strives to provide members access to leading health care professionals in all specialties. All physicians and practitioners requesting network status with Highmark Delaware are required to complete and participate in the application and credentialing process.
Highmark Delaware’s Participating Provider Network supports all products available from Highmark Delaware, including Blue Classic traditional, Blue Choice PPO, Simply Blue EPO, Blue Select POS, the MedicFill Medicare supplemental program, and the Blue Care Independent Practice Association (IPA) managed care HMO product. The network also supports FEP and BlueCard.
West Virginia
Highmark Blue Cross Blue Shield (WV) contracts with providers who have service locations within either the state of West Virginia or a contiguous county. Highmark West Virginia uses provider networks for all of its health benefits lines of business.
Highmark West Virginia professional provider networks include the following:
- Indemnity
- Preferred Provider Organization (PPO)
- Point of Service (POS)
- Medicare Advantage Freedom Blue PPO
Providers sign a Network Agreement, which includes an Addendum I to Network Agreement for Super Blue PPO and POS Participants. The Network Agreement includes an Addendum II to Network Agreement for Super Blue Select Primary Care Physicians for those primary care physicians who act as care coordinators for members in Highmark West Virginia POS products.
Participation in the Freedom Blue network is governed by an Amendment to Network Agreement for Medicare Advantage PPO Program(s); for certain providers not participating in Highmark West Virginia’s commercial networks, this may be a standalone agreement.
New providers contracting with Highmark West Virginia are required to participate in the indemnity, PPO, and POS commercial networks. New providers are encouraged but not required to participate in the Medicare Advantage Freedom Blue PPO network. Network providers may elect to opt out of the Freedom Blue network by providing written notice to Highmark West Virginia pursuant to the Medicare Advantage amendment/agreement.
The West Virginia Small Business Plan (WVSBP) uses the Highmark West Virginia commercial PPO network. Providers may opt out of the WVSBP but remain in the Highmark West Virginia PPO network through an annual opt-out process administered by the West Virginia Public Employees Insurance Agency (PEIA).
To provide high-quality, cost-effective options to Highmark members in Pennsylvania, Highmark has contracted with certain durable medical equipment (DME) providers to form the Select DME Network. The more efficient, lower-cost network will provide a better value for Highmark members’ health care dollars.
Highmark has carefully evaluated and selected providers for the Select DME Network to ensure that all counties in Pennsylvania have adequate coverage to meet members’ needs. Additionally, there are several Select DME Network providers that provide DME on a national scale and are able to serve all counties in Pennsylvania.
Select DME Network
The Select DME Network is the exclusive network for all Highmark Medicare Advantage plans in Pennsylvania. For coverage of eligible DME services or supplies, Medicare Advantage members must obtain the services or supplies from a provider participating in the Select DME Network.
For Highmark commercial benefit plans, the Select DME Network applies to the highest tier level of Pennsylvania tiered health plans. For example, for a 3-tiered plan such as Connect Blue in western Pennsylvania, the Select DME Network applies to the Preferred tier level. In a two-tiered plan such as Community Blue Flex, Community Blue Premier Flex, and Alliance Flex Blue, the Select DME Network applies to the Enhanced tier level. Highmark commercial members with tiered plans have the option of choosing other DME participating providers not in the Select DME Network; however, receiving services or supplies from non-Select DME Network providers may result in higher out-of-pocket costs for members.
For More Information
Highmark provides two versions of the current list of providers in the Select DME Network. You can select a list of all participating providers or a list organized by category, which includes telephone numbers. These lists of providers in the Select DME Network are also available on the Provider Resource Center. From the main menu at the top of the page, select Provider Network, then High-Performance Networks and then choose Select Durable Medical Equipment Network.
Select DME Network providers can be contacted directly if you have any questions about the products or services they provide.
Referring Highmark Members to DME Providers
Providers should refer their Highmark Medicare Advantage patients to Select DME Network providers for their DME equipment and supplies. Receiving services from non-Select DME Network providers would result in higher out-of-pocket costs for the member.
Highmark commercial members can continue to use providers from the broader DME network; however, you should refer Highmark commercial members to Select DME Network providers to receive the highest level of benefits possible.
Highmark network providers must refer members who need additional, non-emergent services to other providers who participate in the network associated with the member’s benefit plan (i.e., PPO, POS, Medicare Advantage). This protects the member from higher costs that may be incurred if services are received from a out-of-network provider.
Background
Many of Highmark’s products have a requirement that members have all their care rendered by providers who hold a contract with the appropriate Highmark network.
- Health Maintenance Organization (HMO), Independent Practice Association (IPA), and Exclusive Provider Organization (EPO) products provide no benefits for non-emergent services rendered by out-of-network providers. An HMO, IPA, or EPO member is responsible for the entire cost of out-of- network services unless in rare cases where a service is not available in the network.
- Preferred Provider Organization (PPO), Point of Service (POS), and open access products feature a lower level of payment when non-emergent services are rendered by an out-of-network provider. A PPO, POS, or open access member who receives a service from an out-of-network provider is responsible for out-of-network deductible and coinsurance amounts before the insurance begins to cover the expense unless in rare cases where the service is not available in the network.
For additional program and product information, please see the Highmark Provider Manual’s Chapter 2: Product Information.
Participating Provider Responsibilities
It is the obligation of providers who participate in a managed care network to provide services at the most appropriate level and to protect Highmark members from business practices that expose them to unnecessary out-of-pocket expenses. This means, among other things, that when your Highmark members require services that you are not able to provide, you are obligated to direct those members to other providers who participate in the network associated with their benefit program.
You are not permitted to direct Highmark members to out-of-network providers unless the member elects to use an out-of-network provider, has out-of-network coverage, and/or the use of such providers has been authorized by Highmark’s Clinical Services or, in some cases, by a Highmark Medical Director.
Locating Network Providers
The online Highmark Provider Directory allows providers to search for Highmark network participating providers. It can be accessed from the footer on the home page of each of Highmark’s regional Provider Resource Center websites:
- https://hbcbs.highmarkprc.com/ - serving the 29 counties of western Pennsylvania.
- https://hbs.highmarkprc.com/ - serving the 21 counties of central Pennsylvania, 5 counties of southeastern Pennsylvania, the Lehigh Valley, and the 14 counties of Northeastern Pennsylvania,
- https://hdebcbs.highmarkprc.com/ - serving the three counties of Delaware.
- https://hwvbcbs.highmarkprc.com/ - serving the entire state of West Virginia.
- https://hwnybcbs.highmarkprc.com/ - serving eight counties in Western New York.
- https://hnenybs.highmarkprc.com/ - serving 13 counties in Northeastern New York.
Providers can also search for participating providers through Availity.
Out-of-Network Services
If a treating provider cannot identify a physician or facility (in or out of network) to which to refer a patient (e.g., for highly specialized, unusual, or infrequently performed services), then the provider may contact Highmark’s Clinical Services for assistance.
Highmark care management staff will attempt to identify one or more in-network providers who perform the service in question. If we cannot locate an in-network provider, we will work with other sources to identify out-of-network providers who may perform the service. If the services are medically necessary, Clinical Services will authorize the use of an out-of-network and approve in-network benefits.
Type of Provider Choice
When more than one type of provider can furnish a particular service or item covered by the member’s benefit plan, Highmark generally does not restrict a member’s or referring provider’s choice of what type of provider to use.
Consistent with provider anti-discrimination law, Highmark plans do not impose limitations or conditions on services, diagnoses, or treatment by a particular type of provider that do not apply equally to all types of licensed providers that customarily provide such services.
Highmark’s benefit plans do generally provide services that must be:
- Furnished by licensed (or certified, where applicable) providers practicing within the scope of their license;
- Rendered according to generally accepted medical standards and practices;
- Provided by someone other than an immediate family member; and
- The most appropriate supply or level of service which can be safely and adequately provided to the member in the most cost-effective setting.
To be registered on Highmark’s files and submit claims to Highmark, eligible providers who are not participating in Highmark’s networks must submit their rendering and billing National Provider Identifiers (NPIs).
Information on obtaining an NPI is provided in the section within this unit titled “National Provider Identifier (NPI).”
Submit NPIs to Highmark
To be registered on Highmark’s files in these service areas, eligible providers must submit their rendering and billing NPIs to Highmark.
Fax to: 800-236-8641
Mail to: Highmark Blue Shield
Provider Information Management
P.O. Box 898842
Camp Hill, PA 17089-8842
Highmark’s Participating Provider Network (Par Network) in Pennsylvania — which services Highmark’s traditional programs as well as BlueCard® traditional, point of service (POS), and health maintenance organization (HMO) programs — is not a credentialed network. A professional provider’s admission to the network is based solely on Pennsylvania licensure and the execution of a Highmark Professional Agreement.
Participating Providers agree to perform services for members according to the applicable Participating Provider provisions (Part I and Part II) of the Highmark Blue Shield Regulations for Participating Providers and Premier Blue Shield Providers, Pennsylvania state laws, the corporate bylaws governing Highmark Blue Shield, and master contracts.
Highmark Professional Agreement Form
A provider who completes the credentialing process to participate in Highmark’s Pennsylvania credentialed networks will automatically be sent a Highmark Professional Agreement and be eligible to participate in the Par Network. However, if a provider would like to forego credentialing and participate only in the Par Network, a provider must complete a “Highmark Professional Agreement” by submitting the completed agreement. A solo practitioner is entering into the agreement as both “Participating Provider” and “Practitioner”. In a group practice, the Participating Provider is entering into the agreement on its own behalf and on behalf of each of its employed practitioners.
The “Highmark Professional Agreement” can be requested through the Request for Assignment Account form or, if not setting up a new Assignment Account, through the Request to be a Highmark Professional Pennsylvania Participating Provider form under the Provider Information Management Forms section on the Provider Resource Center. You will also find the Regulations for Participating Providers in this section.
Facility and Ancillary providers can use the Initial Application for Facility and Ancillary Providers under the Credentialing section of the Provider Resource Center.
The completed Highmark Professional Agreement can be sent to Highmark along with a copy of your current license if a solo practitioner. If a group practice, submit a copy of the license of each practitioner. The Participating Network Agreement and license(s) can be sent by using the Contract Upload Form under the Provider Information Management Forms section on the Provider Resource Center.
Once the completed agreement is received and processed, you will be notified in writing of the effective date of your participation.
To participate in Highmark’s credentialed networks, the professional provider begins the application process through CAQH ProView™ – the online credentialing database developed by the Council for Affordable Quality Healthcare (CAQH). The CAQH ProView national standardized online system eliminates the need for multiple credentialing applications and significantly streamlines the credentialing process. Practitioners complete one standard application that meets the needs of Highmark and other participating health plans and health care organizations.
Highmark uses CAQH ProView as the exclusive provider credentialing system for all applicable networks. All Highmark network providers in the Pennsylvania and Delaware service areas must use CAQH for credentialing and recredentialing.
Once CAQH ProView registration is completed, the provider will receive additional information for completing the application process for participation in the networks within our service areas.
After careful review of your application, Highmark will advise you in writing of your acceptance or non-acceptance into the network(s). A formal appeals process is available to any provider whose application is not accepted. This information is detailed in the communication you will receive.
Important: Mandated WV Uniform Credentialing Form
To initiate the credentialing process, Highmark Blue Cross Blue Shield (WV) physicians and allied health practitioners must complete the most recent version of the State of West Virginia Uniform Credentialing Form (application), preferably by entering information into the CAQH database, as long as it is printed on the mandated West Virginia Uniform Credentialing Form (application).
For More Information
For complete details on CAQH ProView and the credentialing process, please see Chapter 3 Unit 2: Professional Credentialing.
Some customers choose to have more than one professional provider network support their managed care coverage program in Pennsylvania. These programs have both a primary provider network and a secondary network comprised solely of Highmark Blue Shield’s Participating Provider network. The Pennsylvania Insurance Department and Pennsylvania Department of Health have approved these dual-network programs.
Dual-network managed care programs use a separate, supplemental member contract. This contract applies when a member chooses to receive services from a participating provider not in the primary network. Payment under the supplemental contract is based on Usual, Customary, and Reasonable (UCR). Service benefits apply when a Highmark Blue Shield participating provider renders the services.
The Explanation of Benefits form that accompanies the UCR payment states that a Participating Provider must accept the UCR allowance as payment in full for covered services, in accordance with the terms of the Participating Provider agreement. The participating provider may collect any applicable coinsurance or deductibles from the member.
An assignment account is an account established by Highmark to permit one or more individual professional providers, practicing together, to direct Highmark payments to an entity other than the individual provider(s).
An assignment account will be permitted only if the provider(s), as well as the entity to which payment is being directed, meet and continue to comply with guidelines set forth by Highmark.
Eligible Entities and Arrangements
To establish an assignment account, the following conditions must be met:
- The billing entity must be arranged in one of these manners:
- Incorporated solo practitioner – An incorporated solo practitioner who desires to have the corporation recognized as the entity or to use a tax identification number to receive payment from Highmark.
- Sole proprietorship – A sole proprietorship is unincorporated, owned by one individual, and its liabilities are the sole proprietor’s personal liabilities. The sole proprietor takes the risks of the business for all assets owned. For legal and tax purposes, the business does not exist separately from the owner.
- Group practice – Two or more providers practicing as a group may establish an assignment account to have the group recognized as a single entity for purposes of billing and payment. Examples of a typical group practice arrangement are:
- Two or more providers practice as a partnership;
- A group of providers form a professional corporation and the corporation becomes the employer of the providers;
- A provider employs one or more other providers as associates in his or her practice.
- A provider not participating in a Highmark provider network may not be included in a Highmark assignment account which also contains participating providers.
How to Establish an Assignment Account
To establish an assignment account, complete the Request for Assignment Account electronic form. This form can also be found on the Provider Resource Center – select Resources & Education, then Provider Information Management Forms.
Note: To establish a Medicare assignment account, call Medicare Provider Enrollment Services at 866-488-0549.
Important: Assignment Account Regulations
For complete guidelines for assignment accounts, including detailed descriptions of eligible entities, please refer to the Assignment Account Regulations.
The regulations are also available on the Provider Resource Center under Forms, and then Provider Information Management Forms.
Electronic Transactions Required
All Highmark network participating providers are required to enroll in Availity®, Electronic Funds Transfer (EFT), and paperless Explanation of Benefits (EOB) statements. All new assignment accounts must sign up for Availity and also enroll in EFT and paperless EOBs.
Availity is Highmark’s provider portal, which integrates all insurer-provider transactions into one system (e.g., eligibility and benefit inquiries, claim status inquiries, claim submission, authorization requests, etc.). EFT is a secure process that directs Highmark claim payments to the provider’s checking or savings account as directed by your office. Paperless EOB statements reduce the amount of paper flowing into the provider’s office.
For information on enrolling in Availity, EFT, and paperless EOBs, please see the Electronic Transaction Requirements section of this unit.
Keeping Assignment Account Information Up-to-Date
Please inform Highmark of any changes to your assignment account. Failure to keep this data current may lead to incorrect listing in directories viewed by Highmark members, missed mailings or checks, and, possibly, incorrect payments.
Please notify Highmark immediately when any of the following changes:
- Hours of operation
- Practice address (physical location)
- Mailing address if different from practice address
- Specialty (requires signatures of Assignment Account members if you are changing their individual specialties as well)
- Tax Identification Number (TIN)
- Additions/deletions of Assignment Account members
- Telephone number, including area code (member access phone number)
- Fax number
Notification of New or Departing Practitioners
When a practitioner leaves or a new practitioner joins your assignment account, please provide prior notice to Highmark.
Please notify Highmark of a departing provider’s new address and tax identification number – an employer identification number or Social Security number, as appropriate. Highmark will send written notification to departing providers to advise them of the transfer of their profiles to their individual provider number.
Availity is the preferred method for notifying Highmark of practitioner changes. Please continue reading this unit for additional information on making changes to an existing assignment account.
Restrictions
Highmark has the right to deny a request to add or delete any practitioner from an Assignment Account. Highmark will always deny such a request when a utilization case is open that is pending resolution.
How to Make Changes to an Existing Assignment Account
You can notify Highmark of any changes to your existing assignment account quickly and easily by using Availity, Highmark’s preferred method for updating your assignment account information. Select Provider Data Maintenance or Provider File Management (Delaware, Pennsylvania, and West Virginia only) in Availity's Payer Spaces.
- Practitioner Updates: For new practitioners, click on the Add a Practitioner link. To change information for an existing practitioner or to remove a practitioner, select the practitioner, and then click on Edit or Delete, as applicable.
- Address Updates: To add a new location, click on Add an Address. To make changes to an existing address, select the address, and then click Edit or Delete, as applicable.
If you are not Availity-enabled, complete the applicable form as follows:
- Practitioner Updates: For practitioner changes, use the Addition to Existing Assignment Account electronic form.
- Address Updates: For adding new practice locations or to make changes to an existing location, complete the Provider Directory Update Form.
These forms can also be accessed on the Provider Resource Center – select Resources & Education, and then Provider Information Management Forms.
The completed Provider File Maintenance Request form can be faxed or mailed as follows:
Fax to: 800-236-8641
Mail to: Highmark Blue Shield
Provider Information Management
P.O. Box 898842
Camp Hill, PA 17089-8842
Note:
New York: After becoming Availity-enabled, providers must also enroll in electronic funds transfer (EFT) and paperless Explanation of Benefits (EOB) statements. To do this, please contact the Provider Service Center.
Delaware, Pennsylvania, and West Virginia: Changes to your electronic funds transfer (EFT) can be done through the ECHO portal. Please see the Electronic Transaction Requirements section of this unit for more information on how to contact ECHO/change your EFT preferences.
Important!
If going from a solo practice to a group practice and adding practitioners, you will need to create a new assignment account.
Highmark’s Use of Provider Tax Identification Numbers
In addition to claims processing, Highmark uses a provider’s tax identification number to accurately identify providers for other business functions and with outside vendors/partners during the normal course of business operations.
Highmark strongly discourages the use of Social Security numbers in lieu of business tax identification numbers whenever it requests a provider’s tax identification number.
A provider who chooses to submit his or her Social Security number as a tax identification number hereby acknowledges, understands, and agrees that Highmark will treat the Social Security number in the same manner in which it handles other providers’ business tax identification numbers and shall not be liable to such provider for any intentional or unintentional disclosures of such Social Security number.
How to Obtain a Federal Employer Identification Number (EIN)
To avoid using your Social Security number as your provider tax identification number, you may instead use a Federal Employer Identification Number (EIN) issued by the Internal Revenue Service (IRS).
To obtain an EIN, please visit irs.gov.
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans.
The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.
What is The “NPI”?
The National Provider Identifier (NPI) is a 10-digit numerical identifier for providers of health care services. The NPI is a result of the CMS mandate which supports the HIPAA simplification standards. All eligible health care providers receive one standard number which they are required to use when submitting health care transactions. It is intended to improve the efficiency of the health care system and to help reduce fraud and abuse.
Individual practitioners receive one NPI even when they are dual licensed under multiple provider types (e.g., a practitioner holds both an MD and DMD license). Organizational providers (group practices and facilities) receive one NPI for the legal entity and any subpart that meets the covered health care provider definition if it were a separate legal entity. Organizations may request additional NPIs for subparts as long as the identifying data is unique.
How to Obtain an NPI
NPPES is the central electronic enumerating system in place for assigning NPIs. Health care providers can apply for NPIs in one of three ways:
- Complete the web-based application process online.
- Download and complete a paper application from the NPPES website and mail to NPPES.
- Call NPPES for a paper application: 800-465-3203 (800-692-2326)
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.
