Chapter 5 – Care and Quality Management

Care management incorporates a comprehensive integrated solution that encompasses all aspects of engagement and self-management by providing information, support, and interventions across the continuum of care.

The Highmark Care Management Program focuses on the integration of the delivery of health care services with our members, their employers or groups, and our network providers. It is designed to comply with all federal, state, and external review body regulations and standards.

Highmark requires authorization of all inpatient admissions, medical and behavioral health. In addition, authorization is required for certain outpatient services, procedures, and durable medical equipment and supplies prior to performing the services or providing the supplies.

This unit outlines Highmark and Centers for Medicare & Medicaid Services (CMS) procedures and processes specifically for Medicare Advantage members.

Highmark Behavioral Health Services provides behavioral health medical management services for members enrolled in Highmark programs.

This unit outlines Highmark’s procedures for handling denials, adverse benefit determinations, grievances, and appeals.

The Highmark Quality Management Program is designed to ensure that members receive the best quality health care, in the most appropriate setting, in the most cost-effective manner.

Highmark’s network management methodology utilizes value-based reimbursement models, performance, and high-value networks and products. This strategy emphasizes efficiency and appropriateness over volume and waste, encourages provider/payer collaboration, and increases quality and cost improvement potential.

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.