Chapter 6 – Billing and Payment

This chapter provides guidelines that apply to both electronic and paper billings and payments and is applicable to both professional and facility providers.

In today’s business world, there are no requirements to submit claims on paper. Electronic transactions and online communications have become integral to health care. In fact, Highmark’s claim system places higher priority on processing and payment of claims filed electronically. 

All it takes is a computer, the proper software, and an Internet connection for electronic claims submission. Instead of printing, bundling, and sending paper claims through the mail, simply enter and store claims data through your office computer.

Highmark requires facility providers to bill electronically via 837 Institutional (837I) electronic transactions. HIPAA-compliant UB Claim Submission is also available in Availity^®. In some cases, claim submission may be necessary on UB-04 paper claim forms.

Highmark’s claim system places higher priority on processing and payment of claims filed electronically. This unit provides general guidelines applicable to both paper and electronic 1500/837P professional claim submissions.

The 1500 Health Insurance Claim Form (“1500 Claim Form”) answers the needs of many health care payers. It is the basic claim form required by many payers for paper claims submitted by physicians and other professional providers.

Coordination of benefits (COB) applies when a patient is covered by two or more health insurance policies. Highmark employs several processes to ensure the services provided to our members are paid by the proper insurer and the reimbursement for these services does not exceed the actual charge.

This unit addresses payment methodology for both professional and facility provider types, Explanation of Benefits (EOBs), the Facility Remittance Advice, guidance for overpayments and refunds, and special circumstances, such as payment for Federal Employee Program (FEP) members over 65 years of age.

Payment review¹ is a key element of the screening process Highmark uses to assure that members receive health care services that are medically necessary and that the claims for these services are submitted properly. This process also ensures that claims are being paid in accordance with provider agreements, while at the same time addressing the integrity of the payment calculated by Highmark.

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.