Chapter 7 - Appendix
This appendix covers Medicare Advantage (MA) member Evidence of Coverage Booklets (EOCs), MA compliance language, Article VIII Bylaws of Highmark, Review Committee Guidelines, Third Party Codes of Conduct, Professional Regulations, Legal Information, and Highmark’s disclaimer.
Unit 1: Medicare Advantage Member Evidence of Coverage Booklets
The Medicare Advantage Member Evidence of Coverage Booklets explain how Medicare Advantage members get their health care and drug coverage.
Unit 2: Medicare Advantage Compliance Language
The regulations governing the Medicare Advantage program set forth required terms for both Medicare Advantage plans and contracted providers. In order to make contracted providers aware of such terms, the Centers for Medicare & Medicaid Services (“CMS”) has created a contracting checklist for Medicare Advantage plans to follow in developing providers’ contracts and related policies and procedures.
Unit 3: Article VIII of the Bylaws of Highmark, Inc.
These bylaws includes subjects such as general topics; the Medical Review Committee Selection Committee; the appointment, terms and removal of Medical Review Committee Members; officers of the Medical Review Committee; the submission and proceedings; and the proceedings involving status of registered health service doctors.
Unit 4: Review Committee Guidelines
Highmark Inc. (“Highmark”), doing business as Highmark Blue Shield, operates under the provisions of Act 271 of 1972 (40 PA. C.S. Section 6301 et seq.). Section 6324 (c) of the Act requires that all matters, disputes or controversies relating to professional health service doctors or any questions involving professional ethics shall be considered and determined only by health service doctors selected in a manner prescribed in the Bylaws of the professional health service corporation involved.
Unit 5: Third Party Code of Conduct
The Third Party Code of Conduct includes expectations of providers and their staffs when conducting business with and/or on behalf of Highmark.
Unit 6: Professional Regulations
This unit includes links to Highmark professional regulations for participating providers.
Unit 7: Medicare Advantage Supplemental Requirements
This unit includes a supplemental document to Highmark's Medicare Acute Care Provider Agreement. For providers in Pennsylvania and West Virginia.
Unit 8: Legal Information
The information in this manual is issued by Highmark Inc. d/b/a Highmark Blue Shield on behalf of its affiliated Blue companies, which serve the regions set forth in this unit and which are independent licensees of the Blue Cross and Blue Shield Association.
Unit 9: Disclaimer
This unit includes Highmark’s disclaimers about this provider manual.
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.
