Unit 6: Quality Management

5.6 Quality Management Program Overview

5.6 Highmark Quality Program Committees

5.6 Functional Areas and Their Responsibilities

5.6 Case Review Process for Quality Concerns

5.6 Corrective Action and Sanctioning

5.6 Clinical Quality

5.6 Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations

5.6 Service Quality

5.6 Highmark Quality Initiatives

5.6 Peer Review Protections

5.6 Disclaimers

5.6 Quality Management Program Overview

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.

Quality Management follows a Continuous Quality Improvement Process model for the ongoing monitoring and analysis of relevant clinical and service quality measures. The model focuses on the early identification of problems, with the development and implementation of interventions that focus on any issues that are identified. The member is at the heart of all activities.

The purpose of the Quality Management Program is to provide the framework and the formal processes within which the organization continually assesses and improves the quality of clinical care, safety, and service to members.

Definitions

Quality improvement processes are those activities that the health plan undertakes to improve the quality and safety of clinical care (including behavioral health care) and the quality of service to members.

Quality management is the integrative process that links knowledge, structure, and processes together throughout the organization to assess and improve quality.

Highmark Quality Management

Highmark's Health Plan Clinical Quality area, part of the Health Plan Chief Medical Officer (CMO) Organization division of Highmark, is responsible for corporation-wide coordination of clinical and service-related improvement initiatives focused on clinical care, member satisfaction, access and availability, and performance measures and outcomes for both physicians and facilities.

Quality Management is also accountable for compliance with all applicable external accrediting and regulatory entities such as the:

• Centers for Medicare & Medicaid Services (CMS)
• National Committee for Quality Assurance (NCQA)
• Office of Personnel Management (OPM)
• State health and insurance departments

Organizational Structure

The organizational structure of Highmark's Quality Management divides staff responsibilities into these distinct functional areas:

• HEDIS/CAHPS/FEP
• Quality Care and Quality Audits
• Clinical Outcomes and Guidelines
• Clinical Quality Assurance

The Risk & Compliance Management area – which is part of the Enterprise Risk & Governance division – also supports the quality management program from an accreditation and regulatory compliance perspective.

These areas work together with the support of staff from other departments in Highmark, as well as external support from primary and specialty care providers to continually assess and improve the quality of clinical care, safety, and service to members.

Overall Objectives of the Quality Program

The objectives of the Quality Program are as follows:

1. Continuously improve client and member experience of care, as well as their health, by anticipating and evaluating their needs and proactively aligning those needs with appropriate programs and services that reduce and/or control clinical risk.
2. Support and promote the delivery of care by providing a high-quality network of practitioners and providers.
3. Offer data-driven, evidenced-based, and comprehensive health care services and programs that are continuously improved based on outcomes.
4. Build effective partnerships with members and their caregivers/families, clients, providers, facilities, payers, and the community to understand their objectives and needs while adapting products and/or services accordingly to create positive and lasting change and a differentiated member and provider experience.
5. Utilize advanced analytics and proven quality improvement strategies and tools to measure and improve outcomes of care and service and achieve meaningful and sustainable improvement.
6. Enhance transparency efforts to promote member engagement and customer intimacy, while supporting members in making appropriate decisions about care.
7. Continue to work toward achieving health equity through reducing health care disparities, enhancing health literacy, and providing culturally and linguistically appropriate services.

Data Sources

The Highmark Quality Program provides a framework for continuous assessment and improvement of all aspects of health care delivery and services for its membership. This involves the collection and quantitative/qualitative analyses of relevant data to identify barriers or causes for less-than-optimal performance, identification of opportunities for improvement, and implementation of interventions to improve results.

Examples of the various data sources that may be collected and analyzed include, but are not limited to, the following:

1. Medical/treatment records
2. Claims
3. Enrollment reports
4. Pharmacy data
5. Condition management reports
6. Health risk appraisals
7. Member service data
8. Healthcare Effectiveness Data and Information Set (HEDIS®) results
9. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) results
10. Health Outcome Survey results
11. Utilization Management (UM) statistics
12. Member/practitioner surveys
13. Current literature

Behavioral Health

The coordination of behavioral health programs is based on an analysis of the demographic, cultural, clinical, and risk characteristics of Highmark members who utilize behavioral health services.

Highmark developed a Quality Program Description that outlines in greater detail activities to monitor and improve the quality and safety of behavioral health care and the quality of service provided to members. The document outlines the behavioral health aspects of the Quality Program and is reviewed and approved annually by the Highmark Board and appropriate Quality-related committee.

Highmark manages the inpatient utilization of behavioral health services for all members who have behavioral health care coverage through Highmark. Outpatient behavioral health services are authorized in accordance with the behavioral health benefits available for each product.

Behavioral Health Activities

Behavioral health activities have continued to include:

• Access to care and service availability for behavioral health services.
• Communication standards to improve communication between behavioral health practitioners and primary care physicians to enhance continuity and coordination of care.
• Behavioral Health Toolkit available for PCPs which includes Clinical Practice Guidelines as a resource.
• New and ongoing preventive behavioral health clinical initiatives.
• Depression Condition Management Program.

5.6 Highmark Quality Program Committees

As a way for Highmark to promote objective and systematic monitoring, evaluation and continuous quality improvement, various Highmark Program Committees have been established. The Program Committees are made up predominantly of health care professionals and are established by Highmark's Board of Directors.

Highmark Quality, Safety, and Value Committee (HQSVC)

The Highmark Quality, Safety, and Value Committee is a physician-based committee that provides clinical oversight of quality program activities on behalf of the Highmark Board of Directors. The committee reviews quality assurance and improvement activities related to the health benefits administered by Highmark and its applicable wholly owned, wholly controlled, and/or partially owned subsidiaries, and provides input and recommendations on such activities. The HQSVC reviews and approves the quality program description, action plan, and evaluation on an annual basis. The HQSVC also receives quality program reports and updates, as appropriate.

Care Management and Quality Committee (CMQC)

The Care Management and Quality Committee is a multi-disciplinary committee representing Delaware, western and northeastern New York, western, central, and northeastern Pennsylvania, and West Virginia that is dedicated to continuous improvement of quality and care management services provided to members. The Senior Medical Director chairs the CMQC and Medical Directors, actively practicing physicians including behavioral health, and physicians in administrative positions with involvement in care management functions in hospitals are active voting members.

The CMQC has responsibility for the review and approval of the quality, utilization management, and population health management program descriptions, evaluations, and action plans; relevant policies and procedures; utilization core performance indicators/trends; clinical criteria sets used by the plan and its delegates; review, leadership, and direction over Highmark’s care management activities and initiatives; relevant quality improvement activities; oversight/monitoring of all delegated utilization functions, credentialing policies, and desktop procedures as revised; and quality committee reports.

The CMQC is also responsible for recommending policy decisions, analyzing and evaluating the results of quality activities, ensuring provider participation in the quality program, instituting needed actions, and ensuring follow-up, as appropriate. This includes, but is not limited to, the results of quality monitoring activities completed specific to clinical outcomes, member experience, health care equity, member access to services, practitioner and provider availability, continuity and coordination of care, credentialing and recredentialing, delegation and business arrangement oversight, ongoing regulatory and accrediting body compliance, and review and input on clinical practice and preventive health guidelines. 

Clinical Policy Management Committee (CPMC) and Specialty Subcommittees

The Clinical Policy Management Committee (CPMC) is responsible for evaluating medical and surgical procedures and techniques, developing policy guidelines for new and evolving technology and injectable drugs, determining the medical policy coverage positions, and recommending medical necessity guidelines for covered procedures.

Specialty subcommittees — made up of actively practicing physicians in the areas of Cardiology, Hematology/Oncology, Musculoskeletal, Neurosciences, and Pediatrics — evaluate existing medical policy coverage guidelines as well as new technology. The subcommittees meet quarterly and make recommendations to the CPMC regarding medical policy coverage positions.

New York Quality Improvement Program

The focus of the Quality Improvement Program is to continuously assess and improve the care delivered by our participating practitioners/providers and the service delivered by Highmark staff to its members. The organization has the responsibility of designing, measuring, assessing, and continually improving its performance. The result is enhanced health and well-being of the populations we serve.

New York Quality Improvement Program Scope

The scope of the Quality Improvement Program is comprehensive. It includes all Highmark members for all New York operating areas, as well as practitioners and providers who participate in the network. This includes Commercial (HMO, POS, PPO, Federal Employees Program/FEP), EPO, Medicare Advantage, ASO, Essential Plan, and Exchange/Qualified Health Plan products and oversight of Child Health Plus and Medicaid managed care.

The Health Care Quality Improvement Program includes organization-wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to members. The activities include clinical, service, and patient experience.

The Health Care Quality Improvement Program monitors and evaluates a wide variety of clinical and service topics that include, but are not limited to, those listed below:

• Preventive Care
• Disease Management
• Case Management
• Population Health Management
• Utilization Management (including appropriate utilization of services)
• Patient Safety
• Behavioral Health Management
• Culturally and Linguistically Appropriate Services
• Complaint Management for Access to Care or Quality of Care Issues
• Medical Policy
• Pharmacy Management
• Continuity and Coordination of Care

5.6 Functional Areas and Their Responsibilities

The scope of the Clinical Services – Quality area’s functions and responsibilities are described below. These functions are only one piece of the Quality Management Program. In addition, Clinical Services – Quality has established linkages to other areas within Highmark to expand the scope of the Quality Management Program throughout the organization.

Clinical Services Quality

HEDIS/CAHPS/FEP

1. Annual Healthcare Effectiveness Data and Information Sets (HEDIS®) reporting to meet National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS), Office of Personnel Management (OPM), and state regulatory requirements used to assess member utilization of preventive/chronic care services and provider compliance with national standards of care.
2. Annual NCQA HEDIS® Compliance Tool (Roadmap) completion for all applicable products, which includes a review of administration, data management, and processes which serve to collect information about how the plan’s information and management practices comply with HEDIS® reporting requirements and associated on-site audit activities.
   1. One Roadmap and audit process will be completed for the Commercial, Medicare Advantage, and Marketplace products in Delaware, Pennsylvania, and West Virginia.
   2. Another Roadmap and audit process is required separately by the State of PA for the Highmark Healthy Kids (CHIP) HMO product. This audit includes a review of the health information system that is maintained to support data collection and analysis efforts for quality improvement activities.
   3. One roadmap audit process will be completed for Commercial, Essential Plan, Medicare Advantage, and MarketPlace products in New York in addition to the oversight of the New York State Medicaid Product.
3. Annual vendor selection/management for administration and analysis of Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Enrollee Experience Survey (EES) for all applicable products are maintained for identification of improvement opportunities.
   
4. Clinical outcome monitoring, analysis, and planning/design initiatives focused on improving the care provided to the Federal Employee Program (FEP) membership, with targeted focus on measures selected by the Office of Personnel Management (OPM) for its performance improvement program.
5. New York State Quality Assurance Reporting Requirements (QARR) QARR consists of measures from the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS), Centers for Medicare and Medicaid Services (CMS) Quality Rating System (QRS) Technical Specifications, and New York State-specific measures. The products that these reporting requirements apply to are Commercial PPO/POS, Essential Plan, Qualified Health Plans, and Medicaid.

To enhance its ability to monitor measure compliance, New York State continually revises its Quality Assurance Reporting Requirements, adding or modifying measures to provide more comparable and complete information. QARR measures may be modified or changed annually, to reflect both advances in the technology and methodology of measuring quality and new program priorities.

The NYS Department of Health uses the QARR measures and Medicaid encounter data to determine any patterns that may indicate that a particular health plan is not providing appropriate services. If it is determined that a health plan does not achieve an acceptable performance rate, they can be subjected to corrective measures. More specifically, any health plan that does not achieve an acceptable rate of compliance will be required to perform a root cause analysis and to develop an improvement plan approved by the New York State Department of Health.

Quality Care and Quality Audits

1. Patient safety activity monitoring through the review of all internal and external Quality of Care complaints.
   
2. Conduct clinical quality audits to validate appropriateness of utilization management review and approval and provider medical record documentation. Identify opportunities for improvement and collaborate with relevant department on implementing initiatives to improve.
3. Conduct inter-rater reliability testing, scoring, and reporting for UM medical, behavioral health, pharmacy, and medical reviews.
   

Clinical Outcomes & Guidelines

1. Clinical outcome monitoring, analysis, and planning/design of initiatives focused on improving the care provided to members, with targeted focus on the NCQA HEDIS scored measures.
   1. New York: Commercial including Essential Plan, FEP, Medicare Advantage, and MarketPlace QRS. This information is monitored and analyzed at the QARR HEDIS Process Improvement Team meeting.
2. Co-facilitate the Program Outcomes Evaluation and Measures Clinical Work Group (POEM-CWG): Preventive initiatives are developed and implemented by the Clinical Quality staff through the work of the POEM-CWG. HEDIS data is reviewed, barrier analysis performed, and opportunities for improvement identified to target gaps in care that need to be closed and to improve outcomes through interventions targeted toward members and providers.
3. Adoption and distribution of Preventive Health Guidelines that comprehensively address the characteristics and age range of the member population, using evidence-based sources and practitioner input, which are measured annually for guideline compliance.
4. Facilitate the Preventive Health Work Groups to ensure the health plan is compliant with mandates and regulatory guidelines and complete the annual Medicare Advantage and Commercial Preventive Schedules.
5. Member and provider interventions to improve health literacy.
6. Continuity and coordination of care monitoring of transitions within medical care to identify opportunities for improvement and act as appropriate. 

Other Health Plan Clinical/Service Quality Activities (Medical and Behavioral Health)

The below functions are performed by various departments within the health plan/enterprise.

1. Vendor selection/management for administration and analysis of behavioral health experience.
2. Network adequacy plan maintenance and monitoring specific to the Marketplace products.
3. Quality Improvement Strategy (QIS) for Marketplace members.
4. Member preventive health status assessments via claims data analysis, health-risk assessment (HRA) data, PRA-Plus surveys, Medicare Health Outcomes Survey (HOS) results, Personal Health Records (PHRs), etc.
5. Behavioral Health Preventive Program management, such as those components focused on alcohol use screening and depression screening post-cardiac event.
6. Collaboration with Government Quality on the development and reporting of the Chronic Care Improvement Project(s) (CCIPs). Collaboration is also with Clinical Services on interventions that support the CCIP.
7. Practitioner/provider interventions designed to encourage participation in CMS and HHS QI initiatives as applicable.
8. Limited English Proficiency Project Management Office: Civil Rights Act compliance, including arrangements for language assistance services as needed; demographic analyses; Language Assistance Plan monitoring, identification of opportunities for improvement, implementation, and re-measurement.

Enterprise Risk & Governance Functions and Responsibilities

The scope of Enterprise Risk & Governance (ER&G) functions and responsibilities are described below. These functions support the quality program and activities.

1. Ongoing monitoring and continuous audit preparedness for all applicable regulatory and accrediting bodies:
   1. NCQA Health Plan accreditation program management for all products in Delaware, Pennsylvania, and West Virginia.
   2. New York NCQA Accreditation for Commercial and MarketPlace products in New York.
   3. CMS quality-related activities related to Quality Improvement Program components: Quality Improvement Project (QIP) selection, monitoring, and reporting; and Chronic Care Improvement Program (CCIP) selection, monitoring, and reporting in collaboration with Government Quality. The CCIP incorporates at least one activity into the Quality Program to reduce disparities in health/health care among enrollees that is broadly accessible to address relevant disparity.
   4. Pennsylvania Department of Health (PA DOH) and Pennsylvania Insurance Department (PID) annual reporting/technical advisory monitoring for assigned requirements.
   5. Delaware regulatory body monitoring and compliance for assigned activities.
   6. Division of Medicaid and Medical Assistance (DMMA) requirements (credentialing, delegation oversight, and NCQA accreditation only).
2. NCQA contract, project management, and audit coordination: coordinate, prepare, and submit documents for, and participate in, on-site and off-site quality reviews and audits conducted by applicable accrediting and regulatory bodies.
3. Delegation oversight assessment/monitoring: participate in centralized delegation oversight assessment process and ongoing monitoring specific to NCQA requirements.
4. Delegation oversight and reporting for Medicaid HMO products: conduct delegation oversight of non-Highmark affiliated legal entities performing functions on behalf of the Medicaid HMO products in Delaware and report outcomes to applicable committees.
5. Quality improvement structure, governance, maintenance, and operations to support the quality, safety, and equity of clinical care and services provided to members including compilation of an annual Quality Program Evaluation, Description, and Action Plan; reporting matrices; meeting minutes; policies and desktop procedures, etc. (Not applicable for New York. See New York Quality Improvement Program Authority and Structure for more information).  
6. Quality Improvement Strategy that is aligned across the integrated delivery system with common metrics and processes (where possible) and focuses on creating a culture of quality and health.
7. Highmark Population Health Management Strategy that aligns with the Highmark Health strategy.
8. Communications to members and providers regarding Quality Program goals/objectives, progress towards achieving goals, ability to provide input, etc.
9. Health services contracting monitoring to ensure compliance with NCQA requirements.
10. Compliance audits of member notification of practitioner termination and continued access to care to ensure continuity and coordination of care for membership.
11. Oversight of Transition of Care (TOC) procedures to allow new enrollees of a managed care product who are currently in treatment with an out-of-network provider the opportunity to transition his/her care to a network provider.
12. Oversight of process to help inform members and providers of the potential for benefit exhaustion as well as to educate members about available alternatives for continuing care, as appropriate.
13. Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”): Highmark applies the same network admission and provider credentialing standards to all providers in a comparable manner regardless of whether the provider renders medical services, behavioral health services, or substance abuse treatment services. Furthermore, Highmark utilizes the same processes, standards, factors, and strategies to develop provider reimbursement rates for providers that render medical services, behavioral health services, and substance abuse treatment services.
    1. New York Providers: New York State has a Mental Health and Substance Use Disorder Parity Compliance Program. This program establishing corporate governance for parity compliance and ensures appropriate identification and remediation of improper practices.
14. Appointment accessibility monitoring to ensure that members have appropriate access to primary care, behavioral healthcare, and specialty care services.
15. Telephone accessibility monitoring to ensure that members have appropriate access to organizational services.
16. Member experience/satisfaction monitoring (e.g., dissatisfactions, complaints, appeals) and determination of service quality improvement opportunities to correct all problems identified through internal surveillance, complaints, or other mechanisms.  
17. Provider satisfaction monitoring (e.g., Utilization Management [UM] process) through the review and analysis of provider dissatisfactions. Opportunities to improve provider satisfaction are identified and a plan of action implemented, if required.
18. Practitioner and provider availability monitoring to ensure an adequate network of primary care, behavioral health, and specialty care practitioners and providers is maintained, as well as how effectively the network meets the cultural, ethnic, racial, and linguistic needs and preferences of its membership.
19. Continuity and coordination of care monitoring of transitions between medical and behavioral healthcare, identifying opportunities for improvement, and acting as appropriate.

New York Quality Improvement Program Authority and Structure

The ultimate accountability for the Health Care Quality Improvement Program rests with the Board of Directors of Highmark.

The authority and responsibilities for administration and implementation of the Health Care Quality Improvement Program are vested in the Senior Medical Director and Vice President, Health Management. The Corporate Quality Management Committee regularly submit reports to the Board of Directors of Highmark in New York.

QI Committee Structure

To assure that the Health Care Quality Improvement Program is implemented appropriately, key critical responsibilities related to a successful Quality Improvement Program are the shared responsibility of a variety of the committees and subcommittees across the organization.

In support of this shared responsibility the committees, subcommittees, ad hoc committees, etc. will analyze health care-related data from monitoring activities, software program output, and formal studies as appropriate.

These committees consider a variety of actions in relation to data and a number of other activities that are defined in corporate policies. These committees include the Corporate Quality Management Committee, Network Quality and Credentials Committee, Pharmacy and Therapeutics Committee, Medical Management Clinical Committee, Vendor Process Management, Mental Health and Substance Use Disorder Parity Compliance Committee, the Behavioral Health Advisory Board Committee, Wellpoint Joint Oversight Committee, and Highmark Inc./Highmark NY Utilization Management Master Service Agreement (MSA) Joint Oversight.

Monitoring and Evaluation

Results are used to compare with other local plans and regional averages, to revise goals and to target areas of improvement.

• Healthcare Effectiveness Data and Information Set (HEDIS®) measures are primarily clinical in nature, collected annually, audited by an approved contracted vendor, and submitted to NCQA, CMS, and the Blue Cross Blue Shield Association.
• Consumer Assessment of Health Plan Study (CAHPS®) survey provides a measurement of how well the plan/practitioners met members' expectations.
• Quality Assurance Reporting Requirements (QARR) is a set of measures for Commercial HMO, Qualified Health Plans (Marketplace), and Medicaid/Child Health Plus populations based on HEDIS-like data, that are collected annually and sent to the New York State Department of Health (NYSDOH).
• Medicare Touchpoint Measures (MTM) reflect non-clinical service issues (accuracy and timeliness of enrollment, claims and inquiries) and reported semi-annually to the Blue Cross Blue Shield Association.
• Medicare Star Rating is consistent with CMS’ Quality Strategy of optimizing health outcomes by improving quality and transforming the health care system. CMS uses a Five Star Quality Rating System on a scale of 1 to 5, with 5 stars being the highest score a plan can receive and 1 star being the lowest. CMS publishes star ratings in the fall each year and the five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality.
• Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey is a measure set comprised of clinical quality measures, including National Committee for Quality Assurance (NCQA), HEDIS® and a Pharmacy Quality Alliance (PQA) measure. The measure set also includes survey-based measures based on questions from the QHP Enrollee Survey that captures member experience and plan efficiency, affordability, and management. The quality ratings Five Star rating scale is similar to Medicare Star Rating.

Population Health Management Strategy

A variety of clinically based programs are in place for addressing the needs of members across the continuum of care. These include health management programs to address members with complex health care needs, those with physical or developmental disabilities, multiple chronic conditions, and severe mental illness. These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagements in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals to address health disparities through cost-effective and tailored health solutions. 

Delegation

Delegated entities are required to meet specific regulatory standards including NCQA, NYS DOH, and CMS standards. Delegated entities are evaluated annually and key QI and UM documents are reviewed and approved (program descriptions, policies, work plan, and annual evaluations). Joint Oversight Team meetings are conducted to ensure contractual obligations are met. Members document and follow up on operational issues while reviewing and evaluating reports based on performance metrics.

Annual Evaluation of QI Program

To continuously improve the quality and effectiveness of the Health Care Quality Improvement Program, an annual evaluation of the QI program is written and submitted to the Senior Medical Director, Vice President Health Management, Quality Management Committee, and Highmark’s New York Board of Directors.

QI Work Plan

The QI work plan is a working document that reflects ongoing progress on QI activities and updates are noted throughout the year as priorities, needs, and goals of the organization change. A mid-year update is presented to the Quality Management Committee and to Highmark’s New York Board of Directors.

Important: While the New York Quality Improvement Program Authority and Structure includes Medicaid/Child Health Plus populations, Highmark does not have members in these programs in our New York service areas.

(This is the end of NY-specific information in this section.)

Credentialing Compliance

For Credentialing Compliance functions, please see Chapter 3 Unit 2: Professional Provider Credentialing.

Revenue Program Management

Revenue Program Management Functions

Delaware, Pennsylvania, and West Virginia:

1. Professional reviews to determine the adequacy and safety of all professional practitioner office sites, as well as conformance to Highmark Inc. standards for medical record reviews.
2. Facility office site visits and medical record reviews in the absence of external accreditation to determine the adequacy and safety of all facility sites, as well as conformance to Highmark Inc. standards for medical record documentation in response to notification from Credentialing Review requests.
3. Chart abstraction for the annual Healthcare Effectiveness Data and Information Set (HEDIS®) hybrid (medical record) reporting requirement.
4. Educate provider offices relating to Office Site/Medical Record evaluations, HEDIS® medical record review, and/or relating to Revenue Program Management projects.

New York:

1.  New providers and member complaints related to the provider office environment will be reviewed by Provider Networks. This includes, but is not limited to, an assessment of the following office site criteria: access for patients with physical and/or sensory disabilities, physical appearance, adequacy of waiting/exam rooms, organized/systematic clinical record system, confidentiality, 24/7 coverage, appointment access, assessment of medical/treatment record criteria such as: medications, allergies, signature, dated entries, preventive services flow sheet, counseling regarding an advance directive/documentation of executed Advance Directive, etc. Assessments are in response to any of the following:

         a. Specified member complaints

         b. Offices with less than 20 office hours availability

         c. Annual randomly chosen sample

         d. Medical Director requests

2. Facility office site visits and medical record reviews in the absence of external accreditation to determine the adequacy and safety of all facility sites, as well as conformance to Highmark Inc. standards for medical record documentation in response to notification from Credentialing Review requests.

3. Educate provider offices relating to Office Site/Medical Record evaluations and/or relating to Revenue Program Management projects.

5.6 Case Review Process for Quality Concerns

Highmark's Quality Management is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care.

The Clinical Performance Measures area of Quality Management becomes aware of potential issues/concerns and member dissatisfactions about clinical quality of care issues through information received from a variety of sources, including providers, members, and internal Highmark departments.

Important!

Members are able to make clinical quality of care complaints to the health plan.

The Initial Review

A Clinical Quality Management Consultant (CQMC) completes the initial review of each case referred for potential quality of care issues. The CQMC, who is a registered nurse, reviews the case to determine whether there is potential for a quality issue referencing scientifically-based standards of care.

• When this initial review determines that the concern does not have the potential for an adverse outcome, the case is closed and filed for trending purposes.
• If the potential for an adverse outcome is identified, medical records are requested from the provider or facility involved in the case.

The Initial Review

A Clinical Information Associate will determine if a clinical review is needed and applicable information is available (i.e., DOS, permission from member to use name, name and location of provider, HIPAA, if required) or if additional clarification is needed. The member concern is then forwarded to a Clinical Quality Registered Nurse who will request the medical record and a written response to the concerns from the provider.

Analysis of Medical Records

Once medical records are received, the CQMC performs a second assessment of the case. If the assessment dispels any concern of potential for an adverse outcome, the case is closed and filed to track the provider for any future issues.

If the potential for an adverse outcome or a Level of Harm, as defined by the Agency of Healthcare Research and Quality (AHRQ), is identified, the case is forwarded to a Medical Director for review. 

Analysis of Medical Records

Once all needed information is received, concerns are reviewed by a Quality Registered Nurse (RN) to determine if the member’s concern is recommended to be substantiated, not substantiated, or filed and trended (for issues not typically included in medical record documentation). An acknowledgement letter of the decision regarding the clinical complaint/concerns is sent to the member.

Medical Director Review Outcomes

When the Medical Director believes that a quality issue may be present, a written request for additional information is sent to the provider involved.

If it is determined that a quality issue is indeed present following the review of any additional information, a Level of Harm is determined by the Medical Director and a corrective action plan is implemented if warranted.

Medical Director Review Outcomes

If a concern is substantiated and has not already been addressed by the provider in the information previously sent, a Corrective Action Plan should be requested from the provider.

Provider Responsibilities

During the investigation of quality of care concerns, facility providers may be asked to supply any or all of the following:

• A copy of the member’s medical or behavioral health record
• A response from the administrator, or the administrator’s designee, to address a possible adverse outcome determined during the medical record review
• A corrective action plan (if warranted) if an adverse outcome is found during the medical record review

Provider Responsibilities

Every time a concern is sent to a Clinical Quality Registered Nurse, providers must send the following information:

• A copy of the member’s medical or behavioral health record
• A response from the administrator, or the administrator’s designee, to address a possible adverse outcome determined during the medical record review
• A corrective action plan (if warranted) if an adverse outcome is found during the medical record review

5.6 Corrective Action and Sanctioning

Issues Leading to Corrective Action or Sanctioning

A provider or facility is placed under corrective action or sanctioning when a treatment, procedure, or service indicates a provider is not practicing in a manner that is consistent with the standards of Highmark and/or deviates from acceptable standards of care.

There are two issues when a provider can be placed under corrective action/sanctioning:

1. Clinical quality of care – occurs when an episode strays from accepted medical standards (e.g., actions or omissions resulting in an adverse effect on a patient’s well-being, medication errors, missed diagnosis, delaying treatment, unanticipated and unexplained death)
2. Administrative non-compliance – occurs when a provider’s behavior is not consistent with their agreement with Highmark contracts and guidelines (e.g., failure to comply with contractual obligations, medical record review deficiencies, balance billing for services, and unauthorized billing for services)

Notification of Corrective Action

Once the Medical Director makes a determination to place the provider under corrective action, the provider will be notified in writing of:

• The reason for the corrective action
• What corrective action is needed and what it entails
• The period of time the provider will remain under the corrective action

The provider can either appeal the decision of the Medical Director, elect to abide by the corrective action plan, or make the necessary improvements (if applicable).

Appeal Hearing

If an appeal is requested, a hearing with the Network Quality and Credentials Committee (NQCC) will be made available. This committee will make the decision to either uphold or overturn the original decision by the Medical Director.

Sanctioning Possible

After the corrective action time period has expired, the provider will be re-evaluated by the Medical Director. If the Medical Director is satisfied that all stipulations are met, the corrective action will be lifted.

If the stipulations are not met, sanctioning of the provider could occur which may result in a provider’s inability to participate in certain programs.

5.6 Clinical Quality

Preventive Guidelines

Preventive Health Guidelines are available for the entire plan providers, which include:

• Adults ages 65 and over
• Adults ages 19-64
• Pediatric ages 0-18
• Prenatal/Perinatal
• Centers for Disease Control and Prevention (CDC) Immunization Schedules
• Women’s Preventive Services

The Clinical Outcomes and Guidelines Quality team review and update the Preventive Health Guidelines on an annual basis utilizing references such as the United States Preventive Services Task Force (USPSTF), CDC, National Institutes of Health (NIH), Centers for Medicare and Medicaid Services (CMS), etc. The Preventive Health Guidelines are placed on the applicable websites via the Provider Resource Center. A notice regarding the Preventive Schedule is made available via the member website.

These guidelines are available to the provider community as a reference tool to encourage and assist providers in planning their patients’ care.

The Preventive Health Guidelines, and many other valuable clinical resources are available online via the Provider Resource Center. To access these materials, go to the Provider Resource Center and select Resources & Education from the main menu at the top, then Clinical Quality & Education.

Condition Management Program

The Condition Management Program is designed to develop a collaborative working relationship between Highmark members, members’ providers, and Highmark clinicians to support the provider’s plan of care for members under their care. The purpose of the program is to identify members who are most at risk for significant care gaps and, therefore, a progression and/or worsening of their chronic condition. High-risk members are identified through a combination of inpatient and outpatient claims, pharmacy claims, and clinical risk scores that enable our clinicians to conduct outreach to those members by telephone.

Nurses providing condition management services by telephone are known as clinicians. Clinicians work collaboratively with the member and provider to establish realistic and attainable short and long-term goals and to encourage behavior and lifestyle changes that lead to better member self-management of their condition(s). 

Members are eligible to receive health coaching for these chronic conditions:

• Asthma
• COPD
• Depression
• Diabetes
• Heart Disease
• Heart Failure
• High-Risk Pregnancy
• HIV/AIDS
• Metabolic Syndrome
• Musculoskeletal Pain
• Obesity (Pediatric)
• Tobacco Use (CHIP)

Providers, members, and family members can learn about the program and refer to the program by calling the 24/7 health information line at 888-BLUE-428.

Continuity and Coordination of Care

Highmark recognizes the importance of coordination of care as part of the quality continuum. There are programs and policies in place to ensure coordination of medical, behavioral health, or other community support for members. This process enables Highmark to inform the membership of health care needs that require follow-up, training in self-care, and other measures to promote their health.

Clinical Services – Quality facilitates the continuity and coordination of medical care across the delivery system and collaborates with behavioral health practitioners to monitor and improve coordination between medical and behavioral health care. The communication between PCPs and behavioral health specialists is regularly monitored as part of the Highmark Quality Program, specifically through an annual provider satisfaction survey.

Network organizational providers such as hospitals, emergency facilities, ambulatory surgery centers, home health agencies, and skilled nursing facilities must promote continuity and coordination of care for network members by communicating with PCPs when care is delivered to their patients. PCPs should expect a written description of the care given to their patients any time services have been rendered by these providers.

Medical Record Review

Any Practitioner who provides care to our members

Medical record documentation can be assessed at any time using medical record documentation standards that are based on the most recent regulatory guidelines (CMS, NYSDOH, NCQA).

OB/GYN Providers

Medical record documentation will be assessed using the most recent NYSDOH prenatal guidelines. These standards will be used to evaluate compliance in appropriate prenatal medical care for pregnant women.

Purpose

Review of these medical records will improve continuity and quality of patient care by assuring timely, legible, accurate and comprehensive documentation of patient-provider interaction. It will allow Highmark of Western and Northeastern New York to target areas of opportunity to provide education to practitioners on their documentation and areas where medical care can be improved.

Procedure

Medical record documentation standards are based on regulatory guidelines. The standards are reviewed for updates annually.

The medical records for review can be derived from any of the following sources:

• HEDIS/QARR/QRS Review: Healthcare Effectiveness Data and Information Set/Quality Assurance Reporting Requirements/Quality Rating System.
• Quality Concern Review: Records obtained in response to member concerns with access to care and provider requested focused medical reviews.
• Internal Department Referrals: Records identified by Clinical Services, Provider Relations and Contracting, Credentialing, and Financial Investigations and Provider Review (FIPR), as needing Clinical Quality medical record review.
• Continuity and Coordination of Care: Designated projects will coordinate with medical record review to obtain medical records.
• Live Birth File: Records are identified for inclusion in the NYSDOH prenatal medical record review.

Patient Safety Program Activities

Highmark recognizes the importance of patient safety programs; therefore, the Highmark Patient Safety Program focuses on the development of activities which assess and improve the plan’s patient safety efforts.

Many activities have been developed to enhance patient safety, including development of patient-safety-focused, written educational offerings for member and provider communications.

Quality of Care Case Reviews

Clinical Services – Quality of Care is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care and for initiating appropriate action in response to them.

Clinical Services – Quality of Care becomes aware of quality of care dissatisfactions through information received from a number of sources, including providers and members as well as internal Highmark departments. Tracking mechanisms enable Clinical Services – Quality to monitor the information received over time and identify improvement opportunities.

HEDIS^®

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to ensure purchasers and consumers have the information they need to reliably compare the performance of all managed health care plans. Each participating plan reports data for the same measures, so you know you are making comparisons based on similar information.

To ensure these measures encompass data from the entire calendar year, health plans are asked to evaluate and report their results from the prior year. The Plan may be required to report on members from distinct product lines as required to meet and/or maintain National Committee for Quality Assurance (NCQA) accreditation, Centers for Medicare & Medicaid Services (CMS), and/or Office of Personnel Management (OPM) requirements, and/or the Pennsylvania and/or Delaware Department of Health and/or New York Department of Health (PA DOH, DE DOH, NYS DOH) requirements.

Understanding the categories in which plans are rated can help members make a choice based on what is important to them. HEDIS® determines quality and value by measuring success in the following areas:

• Effectiveness of Care: Assesses all types of care (preventive, early detection and screening, maternity, acute, chronic, and behavioral health as well as overuse and appropriateness of care) and populations (children, adolescents, adults, and seniors).
• Access/Availability of Care: Assesses our network providers’ accessibility and timeliness of care.
• Experience of Care: Assesses current members’ levels of satisfaction with the health plan.
• Utilization and Risk Adjustment Utilization: Assesses resource use, how efficiently care is provided, and whether needed services are being delivered.
• Health Plan Descriptive Information: Presents an overview of provider-related information and member demographics.

This reporting occurs on an annual basis and requires the use of administrative claims data, as well as supplemental data feeds through the use of electronic clinical data systems and medical record abstracted data.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

5.6 Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations

Highmark's Office/Facility Site Review Process

Highmark continually strives to enhance the quality of care and services provided to our members. Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations are required to meet Highmark standards as well as those established by regulatory and accrediting organizations. Clinical Quality Management Analysts schedule and conduct Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations for any practitioner within the network based on the following:

1. Member Dissatisfactions: A member dissatisfaction is received when the quality of any practitioner (PCP, specialist, allied health practitioner, or facility) office where care is delivered that is related to any of the following categories:
   1. Physical accessibility
   2. Physical appearance
   3. Adequacy of waiting room and examining/treatment room space
   4. Provider accessibility
2. Annual Random Samples: Using a statistically valid sampling methodology, practice sites in Pennsylvania will be selected for the Practice Office/Facility Site Quality and Medical/Treatment Record Evaluations on an annual basis.
3. Annual Less Than 20 Hours Per Week Sites (PA Only): In accordance with the Pennsylvania Department of Health Managed Care Organization regulations, primary care practitioners must provide office hours at each practice location accessible to members a minimum of 20 hours a week at each practice site in Pennsylvania.
   
   On an annual basis, sites identified as providing less than 20 primary care hours to members will have Practice Office/Facility Site Quality and Medical/Treatment Record Evaluations performed at that site.
4. Facility Site Quality and Medical/Treatment Record Evaluations: Any organizational provider not accredited by a recognized accreditation agency or has not undergone a review by the Centers for Medicare & Medicaid Services (CMS) or the applicable state will have site or medical/treatment evaluations completed.
5. Medical Director Request: Provider/facility sites may have office/facility and medical record evaluations completed as requested by a Highmark Medical Director. 

Scoring Requirements

Follow-up reviews will be conducted within six months of the previous evaluations for all sites that score below Highmark’s threshold of 80% for the practitioner’s office/facility site quality and medical/treatment record evaluations.

Provider office sites and facilities with continuous opportunities for improvement after three consecutive visits at six-month intervals will be presented to the Credentials Committee as exception practitioners for further recommendation. Sites with office deficiencies on repeated re-evaluations may be terminated from network participation.

Review Measures

The following tables include the measures assessed in each component of the evaluation.

Practice Site Resources

Highmark is committed to promoting quality education and care to members and practitioners. Practice Site Resources is a resource for network participating office sites to assist in promoting quality health care to their patients and members.

The resources include a variety of educational resource materials, such as age-specific progress records, preventive health records, and sample office policies to assist the practitioner in meeting Highmark standards, including medical record documentation. Member-specific educational materials are also available for physicians to assist their patients with preventive health care.

The Practice Site Resources materials are used by Highmark Clinical Quality Management Analysts to educate the practitioner office designees when performing office site and medical record documentation reviews.

The Practice Site Resources section is available on Highmark’s Provider Resource Center (PRC) by selecting Resources & Education, then find Practice Site Resources under Clinical Quality & Education.

5.6 Service Quality

Member Satisfaction Monitoring

Annual member satisfaction surveys are conducted, using a statistically valid sample of the membership, to ensure that the plan identifies potential areas for service quality improvements.

Results of the survey are reviewed by Clinical Services - Quality and internal ad-hoc workgroups. The findings are then reported to the Care Management and Quality Committee. Member satisfaction is also monitored through review of member dissatisfactions, complaints, and appeals.

CAHPS^® & QHP EES Survey Results

Highmark contracts with SPH Analytics, an independent research firm certified by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS), to conduct the annual Commercial and Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey and the Qualified Health Plan Enrollee Experience Survey (EES).

The surveys are used to gather information about the overall experiences of our members and to identify areas for improvement.

The CAHPS^® and QHP EES survey results are updated annually and are available on the Provider Resource Center. Select Resources & Education from the main menu at the top of the page, and then Clinical Quality & Education, then  CAHPS^®/QHP EES Survey.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

5.6 Highmark Quality Initiatives

Shared Effort

Highmark considers the pursuit of quality improvement in health care to be a shared effort. While each facility must assess its own needs, establish meaningful goals, and monitor its own progress, Highmark can assist by providing data and opportunities for analysis. Highmark appreciates the cooperation of facilities in collecting data and making good use of it toward improvement of quality in health care services.

The initiatives described here represent just some of the efforts Highmark has made to be a partner with facilities and providers in improving quality in health care.

Medicare Advantage Quality Improvement Program

Medicare Advantage Organizations (MAOs) must have an ongoing Quality Improvement Program per the Centers for Medicare & Medicaid Services (CMS). The Quality Improvement Program includes the Chronic Care Improvement Program (CCIP). The MAO is required to complete a CCIP and attest to that completion annually in the CMS Health Plan Management System (HPMS).

Quality Management selects and implements an annual Quality Improvement Project as determined by CMS. An example of such a project is: “Improving the percentage of diabetic members who are receiving an annual diabetic retinal eye exam.” Representatives from key areas of the Plan meet throughout the year to conduct a quantitative and qualitative analysis on the selected measure. Interventions are then implemented to improve results.

Safety Initiatives

Highmark continuously works to improve the safety of clinical care and services provided to its members. A variety of safety initiatives are conducted at Highmark that focus on both members and providers. One of those initiatives is ensuring that hospitals with over 50 beds implement an evidence-based initiative that improves health care quality through the collection, management, and analysis of patient safety events that reduces all cause preventable harm, prevents hospital readmissions, and/or improves care coordination.

Hospitals with over 50 beds can comply with this initiative by meeting at least one of the following criteria:

• Hospitals in the Commonwealth of Pennsylvania must already comply with the Patient Safety Requirements of Act 13, which includes Department of Health review and approval of Patient Safety Plans to ensure compliance with State-required elements, as well as oversight on an ongoing basis. A hospital in Pennsylvania may submit verification of meeting this state requirement to Highmark to show compliance.
• Obtaining/maintaining accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or another accrediting agency acceptable to Highmark that includes compliance with a Patient Safety Standard as a required component for obtaining accreditation. Highmark will verify this information at the time of a hospital’s initial assessment (prior to contracting) and at least every three years thereafter.
• Producing evidence of participation with a Patient Safety Organization (PSO) and/or a Patient Safety Plan to Highmark as part of the assessment site visit conducted for hospitals that are not accredited. Providing evidence of a CMS Certification Number (CCN) at the time of the assessment and renewal is also required.

Member Outreach Initiatives

The Clinical Outcomes and Guidelines team coordinates the development of member communication activities such as mailings, articles, and outreach to share health information and reminders for clinical services. Monthly mailings are sent to identified members to encourage them to schedule important preventive health screenings, such as for breast, cervical, and colon cancer.

Health Care Disparities Activities

Highmark has made reducing health care disparities a priority.

Member Health Care Education Material

Highmark identified a need for Spanish-speaking members to have access to educational materials translated into their native language. Several of Highmark’s educational materials have been translated into Spanish and are available on the Provider Resource Center under Resources & Education, then Educational Programs, and then Educational Resources – Member and Provider.

Highmark is continuing to evaluate the need for other educational materials to be translated and will implement new translated materials as necessary.

Risk Adjustment Programs

Highmark has both prospective and retrospective coding programs in place to support correct risk scoring of its members and provides resources and education to providers to facilitate correct capture of ongoing conditions on an annual basis.

Goals of Risk Adjustment Programs:

• Support a complete and accurate health record
• Gap closure to engage members who may not be properly managing their chronic conditions
• Support providers to appropriately utilize Medicare Annual Wellness Visits and other encounters to complete health assessments and facilitate gap closure
• Support population health strategies

Provider documentation and coding information is available on the Provider Resource Center – when accessed via Availity® – by selecting Resources & Education. Look under Clinical Quality & Education.

Submitting Claims with More Than 36 Diagnosis Codes

Highmark can accept up to 36 diagnoses for a date of service. If you have more diagnosis codes than the system allows, Highmark has developed the following process to submit additional diagnosis codes:

1. Submit first claim using applicable visit CPT code(s)
2. Submit a second claim using 99499, $0.00. Include the additional diagnoses codes that went beyond the maximum codes allowed from original claim on this new claim. Important: 99499 must be the only CPT code on this claim.
3. If appropriate, submit remaining diagnoses using 99499 with modifier 25, $0.00 on an additional claim

Example: Billing system with a maximum amount of 12 diagnoses per claim:

1. Submit first 12 diagnoses using actual visit CPT code(s)
2. Submit 13 – 24 diagnoses using 99499, $0.00
3. Submit 25 – 36 diagnoses using 99499 with modifier 25, $0.00

If you wish to submit additional diagnosis codes beyond the count of 24 by utilizing 99499 on another separate claim, a modifier 25 must be affixed to the procedure code along with a claim charge of $0.00 to avoid a duplicate claim.

• Highmark classifies 99499 as an eligible procedure code for risk adjustment within the encounter data processing system (EDPS). EDPS filtering is set by CMS, and the government agency lists only 99499 for the submission of additional diagnosis as eligible for risk adjustment. A claim only needs to have one line with an eligible procedure code in order for the entire claim and all of its diagnosis codes to be deemed eligible for risk adjustment. However, if 99499 is billed as a separate claim with a $0.00 charge, the diagnosis codes(s) would be eligible for risk adjustment, but the separate $0.00 claim will be denied/rejected for payment as no payment can be made due to the $0 charge.
• Affix a claim charge amount of $0.00 to the procedure code. This must be the amount recorded.

NOTE: A denial message will show on the EOB stating that this line item could not be processed because a charge amount was not attached. Even though this line item is denied, Highmark will still capture the diagnosis codes affiliated with this procedure code. If a diagnosis code of value was omitted from the original billing, Availity® will allow you to submit the additional codes using 99499 on eligible 1500 claims.

5.6 Peer Review Protections

Protected Activities

Activities of the Highmark Quality Program, including activities of the staff, medical directors, and the Network Quality and Credentials Committee, may be afforded protections as peer review activities under state and federal law. Such protected activities include:

• Evaluating and improving the quality of health care rendered;
• Reducing morbidity and mortality;
• Evaluation by health care professionals of the quality and efficiency of services ordered or performed by other health care professionals (including inpatient hospital and extended care facility utilization review and ambulatory care review); and
• Actions or recommendations of a professional review body, based on the competence or professional conduct of a physician, which could adversely affect the health or welfare of a patient, and which could affect the clinical privileges or plan membership of the physician.

Accordingly, network providers and other peer review bodies (such as hospital quality review committees) may furnish information requested by the Highmark Quality Program and the confidentiality of such information will be maintained and protected pursuant to applicable state and federal laws.

West Virginia Code

Generally, the proceedings and records of a peer review organization are confidential, privileged, are not subject to subpoena or discovery proceedings, and are not to be admitted as evidence in any civil action arising out of the matters that are subject to evaluation and review.

However, information, documents, or records otherwise available from original sources are not to be construed as immune from discovery or use in any civil action merely because they were presented during proceedings of such organization. Please see W.Va. Code §30-3C-1 et seq. for additional information.

5.6 Disclaimers

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.