Unit 7: Payment/EOBs/Remittances

6.7 Overview

6.7 Payment Methodology for Professional Services

6.7 Explanation of Benefits for Medical-Surgical Contracts

6.7 Facility Payment Methodology

6.7 Facility Remittance Advice

6.7 ANSI Claim Adjustment Group and Reason Codes

6.7 Overpayments and Refunds

6.7 Electronic Manual Payments

6.7 Payment for FEP Members Over 65

6.7 Payment for the Highmark Healthy Kids Program (CHIP)

6.7 Non-Network Payment Guidelines

6.7 Disclaimers

6.7 Overview

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.

Highmark Reimbursement Policies

Highmark’s reimbursement policies contain general coding and reimbursement guidelines to help you avoid claim denials and receive timely payment. The policies are reviewed regularly and updated as necessary, with new policies added when a need is identified. When a policy is updated, past versions are stored within the Reimbursement Policy Bulletin and accessed by selecting the Click Here for History Versions link that will appear on the top right of the first page of the bulletin.

To access Highmark’s reimbursement policies on the Provider Resource Center, select Claims & Authorization and then Reimbursement Policies.

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 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.

Medicare Advantage Sequestration Payment Reductions

As part of federal budget cuts mandated by the Sequestration Transparency Act, the Centers for Medicare & Medicaid Services (CMS) initiated a 2% cut in Medicare spending in the form of payment cuts to health care providers for Medicare claims.

Highmark applies sequestration payment reductions similar to those applied by original Medicare. The reductions are applied to all Highmark Medicare Advantage HMO and PPO claim payments after determining any applicable member deductible, member coinsurance, and any applicable Medicare secondary payment adjustments. There is no impact to member cost sharing.

Value-Based Reimbursement

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

Highmark’s value-based reimbursement strategy evaluates providers' ability to deliver the right care at the right time and in the most appropriate setting. Our value-based reimbursement programs place intense focus on care coordination and population health management principles. For more information, please see Highmark’s Provider Manual Chapter 5 Unit 7: Value-Based Reimbursement Programs.

For More Information

Additional information, such as Medical Policy and HCPCS Information, is available under Policies & Programs on the Provider Resource Center to assist you in billing services for reimbursement from Highmark.

6.7 Payment Methodology for Professional Services

Highmark uses several mechanisms to reimburse professional providers for services rendered to its members. These mechanisms vary depending on the program in which the member is enrolled.

Fee Schedule Inquiries

Fee Schedule Inquiries in Availity® can be used to determine allowances for specific codes or to generate a list of frequently reported procedures for a given specialty. Go to Claims & Authorization and then Fee Schedule Information.

Requests for fee schedules for most frequently reported procedures can also be submitted in writing to the address below. Please include your provider name, address, and NPI (National Provider Identifier) on your request.

Highmark Blue Shield
Fee Based Pricing and Analysis
P.O. Box 890089
Camp Hill, PA 17089-0089

The fee information will provide the fee-for-service dollar amount allowable for each CPT code. Highmark will not require the participating physician to provide Highmark with billing rates as a precondition to providing fee information.

Plan Allowance

The Plan Allowance is based on the reimbursement terms contained in the Member’s Plan Documents as well as their reimbursement amount contained in the fee schedule applicable to the product and provider. If the provider's charges are less than the plan allowance for a particular service, the fee paid to the provider for such service will not exceed the provider's charges. Plan Allowance amounts are updated periodically to respond to changing economic and market conditions.

Fee-for-Service Method

Fee-for-service claims are paid using the network fee schedule specific to the service area. For each service, the payment calculation selects the lower of the provider’s billed amount or the Plan Allowance.

Fee-for-service payments may be subject to member program copayments, coinsurance, and deductibles. If the provider's charge is less than the Highmark Plan Allowance, including any incentive payments if applicable, the provider's charge will be paid.

Premier Blue Shield Fee Structure

Premier Blue Shield is Highmark’s statewide selectively contracted network of preferred providers in Pennsylvania. It is not tied to a specific benefits program but supports a variety of Highmark programs.

Premier Blue Shield allowances are based on a fee schedule that emphasizes evaluation and management services. Adjustments to the Premier Blue Shield fee schedule are made, as needed, to assure providers are receiving fair reimbursement — and to assure that members have adequate access to primary care and specialty services.

Premier Blue Shield providers agree to accept Highmark’s allowances as payment-in-full for covered services. Members are responsible for any applicable copayments, deductibles, or coinsurances.

The Premier Blue Shield Network Fee Schedule is available on the Provider Resource Center under Claims & Authorization then Fee Schedule Information.

First Priority Health PCP Payment Methodologies

The First Priority Health (FPH) managed care provider network supports the health maintenance organization (HMO) products in the 13-county Northeastern Region of Pennsylvania, including the Highmark Healthy Kids/Children’s Health Insurance Program (CHIP).

There are several reimbursement methodologies available to primary care physicians (PCPs) participating in the FPH network, including capitation, billables, copayments, and fee-for-service reimbursement as more specifically set forth in your FPH participating provider agreement. For more details, please see Highmark’s Provider Manual Chapter 4 Unit 1: PCPs and Specialists.

Medicare Advantage Claims are Paid Differently

Providers with a Medicare Advantage contract with Highmark are reimbursed for Medicare Advantage claims in accordance with their contracted rate, which is based on the Medicare fee schedule; however, it may not match the Medicare fee schedule exactly.

At a minimum, Medicare Advantage programs are required to provide coverage for the services covered by Traditional Medicare. They may also provide additional services and benefits. While a person is a member of Medicare Advantage, services are not paid by Traditional Medicare except for services incurred during a hospice election period and routine costs associated with clinical trials paid by Medicare.

6.7 Explanation of Benefits for Medical-Surgical Contracts

An Explanation of Benefits (EOB) statement is sent to network professional providers and to members via postal mail or electronically based on preference. Along with the claim payments, network providers receive an EOB listing all claims processed each week. This EOB lists each patient’s claim separately. Each individual member on the provider’s EOB will also receive an EOB listing the services processed. (See example of a provider EOB later in this unit.)

Regardless of your practice location, all Highmark EOBs are available electronically on Availity® by choosing Claims & Payments and then click on Remittance Viewer.

Availity, Electronic EOBS, and EFT

After becoming Availity-enabled, providers must also enroll in electronic funds transfer and paperless Electronic Remittance Advices. For more information on electronic transaction requirements, see Highmark’s Provider Manual Chapter 1 Unit 3: Electronic Solutions – EDI & Availity.

Non-Network Providers

Non-network providers do not receive an EOB. Instead, the member receives the EOB and a check, if applicable. The member is responsible for reimbursing the non-network provider for services performed.

6.7 Facility Payment Methodology

Highmark develops and maintains reimbursement methodologies for facility-type providers (UB-04/837I billers) that allow claims to pay at industry standards while taking into account the specific needs of the network participating facilities in our service areas. Reimbursement is in accordance with the payment and reimbursement terms contained in the provider’s agreement.

Facility Inpatient

Highmark’s general reimbursement methodology for commercial inpatient claims is designed to establish, on a prospective basis, fixed rates for inpatient services. Payment for medical/surgical inpatient services will be made on a per case basis, using the DRG (diagnosis related group) patient classification system.

Highmark develops their own DRG weights. However, the Centers for Medicare & Medicaid Services (CMS) reimbursement methods are reviewed regularly to determine what the impacts are to Highmark’s reimbursement methods. These updates can occur annually or quarterly depending on the provider type.

Facility Outpatient: Highmark OPPS-Based Payment Method

Highmark has adopted the Medicare Outpatient Prospective Payment System (OPPS) that is based on the Ambulatory Payment Classification (APC) system and the use of the OPPS components in Highmark APC-based payment methods. OPPS was designed to pay acute care hospitals for most outpatient services.

The Highmark OPPS-based payment method is designed to use all the features, values, and workings of the Medicare OPPS, with the exception of select customized features. The payment method includes the APC grouper and pricer, relative weights, applicable edits, and quarterly updates.

Since its inception, CMS has made, and continues to make, changes and refinements to APCs and the entire OPPS. These changes are made every calendar quarter, with the most significant changes occurring at the start of each calendar year.

Highmark evaluates the appropriateness of CMS’ new or revised components for potential modification. Highmark’s implementation of each quarterly update is based on the time frame in which CMS releases the quarterly change notices and Highmark’s receipt of such changes via the vendor software. The date of implementation will be posted in advance via the Highmark OPPS calendar on the Provider Resource Center when accessed via Availity®.

For More Information

For more details, you can find the Highmark Outpatient Prospective Payment System (OPPS) Based Payment Method Provider Training Manual and the APC Pricing Component Update Calendar on the Provider Resource Center. Look under Claims & Authorization and then Reimbursement Resources.

SNF RUG-Based Payment Methodology

Highmark currently uses a Resource Utilization Group (RUG) based payment methodology for all participating skilled nursing facility providers for both commercial and Medicare Advantage products. RUG-based reimbursement more closely approximates the relative resource intensity associated with treating individual skilled patients. Each RUG category translates into a per diem payment that is specific to each patient’s condition.

The Highmark methodology is designed to use all the features, values, and workings of the Medicare per diem payment methodology with only a few exceptions.

6.7 Facility Remittance Advice

The Provider Remittance Advice is provided by Highmark’s claim processing system and accounts for all claims adjudicated in the payment cycle, including those which have been denied. The Remittance Advice displays how the claim processes, including contractual adjustments, payments, and member liabilities.

Remittance Types and Availability

The facility Provider Remittance Advice is available in an online version via Availity® by going to Claims & Payments and then clicking on Remittance Viewer.

Providers can also choose to receive their claim payment information via an electronic remittance advice (Version 5010 – 835). Receipt of the 835 can be set up through contacting your electronic vendor or clearinghouse or directly by:

• Delaware, Pennsylvania, and West Virginia: receipt of the 835 is generated from PNC-ECHO Health Trust using the ECHO Payer ID 58379. To sign-up to receive ERAs visit ECHO Health’s EFT/ERA enrollment page.
• New York: Receipt of the 835 is generated from the Administrative Services of Kansas (ASK).

For all Friday evening payment cycles, the 835 is available for viewing by Monday morning. The actual availability of the 835 files may also depend on your vendor.

Electronic Funds Transfer (EFT) payments associated with both the facility Remittance Advice and the Version 5010-835 are available on Wednesday.

EDI Support

For information on electronic remittance advice (Version 5010-835), please visit the Highmark EDI Services website. The EDI website is accessible on the Provider Resource Center by selecting Claims & Authorization then looking under Reimbursement Resources, or by clicking on the applicable link below for your service area:

• Pennsylvania: highmark.com/edi
• Delaware: highmark.com/bcbsde
• West Virginia: highmark.com/edi-wv
• New York: ask-edi.com/

An EDI support analyst may also be contacted by phone at 800-992-0246.

6.7 ANSI Claim Adjustment Group and Reason Codes

American National Standard Institute (ANSI) codes are used to explain the adjudication of a claim and are the CMS-approved ANSI messages. Group codes must be entered with all reason code(s) to establish financial liability for the amount of the adjustment or to identify a post-initial-adjudication adjustment.

ANSI Group Codes (AGC)

The table below defines the ANSI Claim Adjustment Group Codes that appear in the field represented as AGC (column 2, line 4) on the Highmark Remittance Advice Detail Report:

ANSI Reason Codes (ARC)

ANSI Claim Adjustment Reason Codes (CARCs) appear on the remittance, designated as ARC (column 2, line 4), to communicate an adjustment. These codes explain why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code on the remittance.

Below is a list of commonly used Claim Adjustment Reason Codes:

1 Deductible Amount
2 Coinsurance Amount
3 Copayment Amount
18 Duplicate claim/service
29 The time limit for filing has expired.
35 Lifetime benefit maximums have been reached.
49 Non-covered services – Routine
78 Non-covered days/Room charge adjustment
96 Non-covered charge(s)
119 Benefit maximum has been reached for this time period.

For a complete current listing of Claim Adjustment Reason Codes, click here.

6.7 Overpayments and Refunds

Highmark offers streamlined, electronic processes that simplify how you notify Highmark of claim overpayment and how Highmark will notify you when we identify overpayments.

Provider Identifies Overpayment

If a provider identifies an overpayment:

• All Availity-enabled providers must use Message this Payer within Claim Status in Availity to notify Highmark of an overpayment. If you are not Availity-enabled and an overpayment was made, call Highmark Provider Service to advise if you want the overpayment offset from a future payment.
• If Highmark agrees that an overpayment exists, it will adjust the payment so that the next Explanation of Benefits (EOB) statement and Electronic Remittance Advice (835) transaction (if used) will include details of the changes in the payment. It will also reduce the total payment for that EOB/835 by the amount of the overpayment. The EOB/835 detail, on a line-item basis, is clear and easy to post in your accounts receivable software. If you take advantage of the Electronic Remittance Advice (835) transaction, your office/facility can automatically post the refund.
• While less desirable, if you prefer to refund the amount of overpayment by sending a check. Send a check and a copy of the EOB with the overpaid claim circled to:

Chip Provider Self Audit Protocol

Per the Highmark Healthy Kids/Pennsylvania Children’s Health Insurance Program (CHIP) Provider Self Audit Protocol, providers are to mandatorily disclose overpayments or improper payments of CHIP funds within 60 days of identification and provide written description of the reason for the overpayment or improper payment. 

Highmark Identifies an Overpayment

If Highmark identifies an overpayment:

• Highmark will notify your practice of all overpayments on a separate section of the EOB and Electronic Remittance Advice (835) transaction, if used. Highmark will not send notification of overpayment letters to you. The overpayment details in the new section of the EOB (future offset summary) and 835 reference an overpayment that will be withheld from a future check.
• The EOB/835 provides detail as to the reason for the refund request. It serves as notice that unless appealed or paid by check, the overpayment will be deducted from an EOB/835 approximately 60 days following the notification.
• If you agree with the refund request, you should take no action. Highmark will automatically deduct the overpayment from a future check. The deduction will be indicated on your EOB/835. If you do not want the overpayment withheld from a future check but prefer to write a check for the overpayment, send the check and a copy of the EOB with the overpaid claim circled to:

6.7 Electronic Manual Payments

When a manual payment is requested for a provider and the provider is both EFT and Availity®-enabled, Highmark will send the provider an electronic payment instead of a paper check. Electronic manual payments will have a unique check number that will begin with “77” (e.g., 7700000001). An electronic remittance advice/EOB will not be issued for electronic manual payments.

How to Obtain Electronic Manual Payment Information

You can use Availity’s Cash Management function to see payment details for an electronic manual payment. The Cash Management transaction provides a weekly payment accumulation and a summary of payments received for the current year. In addition, you may retrieve individual check details.

To access check details, select Payer Spaces and then select Cash Management. Click on the applicable check number from the list on the Provider Payment and History Inquiry page. You can view additional information about the payment in the Comments field on the check’s Detail Information screen.

6.7 Payment for FEP Members Over 65

Federal Employee Program (FEP)

For certain Federal Employee Program (FEP) members aged 65 or older who do not have Medicare, the Federal Employee Health Benefit (FEHB) law limits payments for inpatient hospital care and physician care to what Medicare would pay. Outpatient hospital care and non-physician based care are not covered by this law.

The following chart provides information about the limits:

The following table explains member responsibility under each plan option:

6.7 Payment for the Highmark Healthy Kids Program (CHIP)

Promise™ ID Enrollment Required for Highmark Healthy Kids (CHIP) Payment

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 Highmark Healthy Kids (CHIP) enrollees to have a valid PROMISe ID. A valid PROMISe ID is required to receive payment for CHIP enrollee claims. Failure to have a valid PROMISe ID may result in denial of reimbursement.

For more information about PROMISe ID enrollment, please see Highmark’s Provider Manual Chapter 3 Unit 1: Network Participation Overview.

Reimbursement

Participating providers accept Highmark’s reimbursement for services as payment in full without balance billing the enrollees. There is no additional discount applied to provider reimbursement rates due to income level (providers receive the full Highmark CHIP reimbursement rate).

For the CHIP HMO plan, if covered services are not available from a network provider, preauthorization must be obtained to receive services from a provider outside the network.

Highmark Healthy Kids (CHIP) Provider Self Audit Protocol

Per the Pennsylvania Children’s Health Insurance Program (CHIP) Provider Self Audit Protocol, providers are to mandatorily disclose overpayments or improper payments of Highmark Healthy Kids (CHIP) funds within 60 days of identification and provide written description of the reason for the overpayment or improper payment.

For more information on reporting overpayments to Highmark, please see the Overpayments and Refunds section of this unit.

FQHC/RHC Payment and Claim Submission

Section 503 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires payment for services provided by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to be at least equivalent to Medicaid Prospective Payment System (PPS) rates for all CHIP encounters. The PPS rates are all-inclusive rates for encounter services provided, except for vaccine services.

All FQHCs and RHCs must bill for services using the T1015 procedure code. The T1015 code is the required code to be able to pay the all-inclusive PPS rate and is defined as “clinic visit/encounter, all-inclusive.” 

When the FQHCs are using the 1500 Claim Form, they must list T1015 in the first section of Item #24d. All pertinent services furnished during the encounter should be listed in the claim. FQHC PPS specific payment codes are listed on the Centers for Medicare & Medicaid Services (CMS) website.

General Guidelines for CHIP FQHC/RHC Claim Submissions:

1. Providers should include the T1015 HCPCS code indicating an encounter/service meeting the guidelines for CHIP has occurred.
2. Providers can either bill the T1015 HCPCS with a charge amount or a zero charge.
3. T1015 code must be billed on the same claim as the office visit and not separately.
4. Reimbursement at the PPS encounter rate may be split across lines on the claim. Base Pricing will prorate the claim allowance on eligible lines to apply the entire encounter/claim allowance to the claim.
5. All other procedures performed during the encounter on the claim (e.g. office visit, screening, behavioral assessment, etc.) must be billed with a charge amount and the procedure CPT code (as they would normally submit). Zero charge lines reported for CHIP enrollees will reject.
6. All vaccines should be billed with charge amounts and associated CPT code and do not need to be billed with the T1015 code.
7. Vaccine administrations should be billed with the charge amounts and associated CPT code and do not need to be billed with the T1015 code.
8. CHIP does not reimburse more than charge. Each claim is capped at charge before any enrollee liability and approved amounts are calculated.
9. CHIP enrollees may be liable for copays based on services.

Questions on FQHC PPS can be emailed to FQHC-PPS@cms.hhs.gov

For More Information

To learn more about Pennsylvania’s CHIP program, please see Highmark’s Provider Manual Chapter 2 Unit 3: Other Government Programs.

6.7 Non-Network Payment Guidelines

Non-network providers do not sign an agreement with Highmark. Therefore, they have no contractual obligation to accept Highmark’s allowance as payment-in-full. However, non-network providers are required to accurately report services performed and fees charged.

6.7 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.