Chapter 4 - Provider Responsibilities and Guidelines

Highmark requires certain responsibilities of providers, and offers guidelines for doing business with us.
We commit to announcing changes to administrative or reimbursement policies with adequate notice.
Consult these units for all provider responsibilities.

While primary care physicians/practitioners (PCPs) play an important role in managing all aspects of
health care for members who select their practice, specialists in Highmark’s networks play an equally
important role of providing specialty services to Highmark members.

Behavioral health benefits vary by product and by group. In some instances, a group may purchase medical
health care coverage through Highmark, but behavioral health care coverage through another company.

This unit includes facility-specific guidelines for facility providers and applies to Commercial and
Medicare Advantage, unless otherwise noted. Section headings will help to identify if the information in
the section is applicable to a specific facility type.

Ancillary care refers to the wide range of health care services provided to support the work of physicians.
To supplement the professional provider and facility networks, Highmark contracts with a network of
ancillary providers that provide health care related equipment or services.

These units offer guidelines on advanced imaging, cardiology, outpatient laboratory services, laboratory
management, diagnostics and cost sharing.

The prescription drug program offers pharmacy networks that include national chains and many local
independent pharmacies. Drug benefits may vary slightly depending on the member’s group program.

Highmark makes every effort to provide resources to assist providers in servicing our members and
working with us. This unit of the manual was developed to provide guidelines for documenting members’
medical records that will help you to have the appropriate documentation readily available for medical
necessity reviews.