1.1 Manual Purpose and History

1.1 How to Use This Manual

1.1 About Highmark

1.1 Highmark Works With Health Care Providers

1.1 Disclaimers

1.1 Manual Purpose and History

The Highmark Provider Manual is designed to be your primary reference guide to Highmark. It contains information, policies, and procedures for all providers participating in Highmark’s provider networks in Delaware, New York, Pennsylvania, and West Virginia, and contiguous counties in their bordering states.The manual combines information for all Highmark service areas to give providers a comprehensive understanding of Highmark’s health insurance programs.

The Highmark Provider Manual, together with other administrative requirements as defined or described in the applicable provider agreement, supplements and is made part of your provider agreement(s). The manual includes, but is not limited to, information such as:

• Services we offer providers and members
• Requirements for participation in our provider networks
• Administrative requirements and guidelines
• Electronic solutions for efficiency and convenience
• Claim submission guidelines for quick and accurate processing

The Highmark Provider Manual is applicable to all provider types who have provider agreements with Highmark, including:

• Physicians and other professional practitioners;
• Hospitals and other facilities; and
• Ancillary and other organizational providers.

Where indicated or as is apparent by the content, certain sections of the manual may not be applicable to all provider types.

Manual History

The online Highmark Provider Manual was first published in 2018, providing one comprehensive resource for all providers participating in Highmark’s provider networks in all service areas in Delaware, New York, Pennsylvania, and West Virginia. This online manual replaces any provider manuals previously used in any of Highmark’s service areas.

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. The Highmark Provider Manual is the property of Highmark Inc. and its affiliated health plans, Highmark BCBSD Inc. (Highmark Blue Cross Blue Shield Delaware), Highmark West Virginia Inc. (Highmark Blue Cross Blue Shield West Virginia), Highmark Blue Cross Blue Shield of Western New York, and Highmark Blue Shield of Northeastern New York (individually and collectively referred to herein as “Highmark”). The information, content, and design/organization of the Highmark Provider Manual are maintained by Highmark. Links to external websites referenced in the manual are for the convenience of the user. Such links do not constitute an official endorsement or approval by Highmark or any of its subsidiaries or affiliates with respect to the links’ content.

Highmark complies with all state and federal laws, including laws related to Medicare and our Medicare Advantage products. In cases where administrative requirements (as defined or described in the applicable provider agreement, including but not limited to, Highmark policy, Highmark Medical Policy, and/or the Highmark Provider Manual) conflict with federal or state laws or regulations, or directives of the Centers for Medicare and Medicaid Services (CMS) or other regulators, such laws, regulations, and/or directives shall apply.

Information in the Highmark Provider Manual is subject to change by Highmark. Information in the Highmark Provider Manual is subject to regulatory review and may also be changed at any time in accordance with regulatory requirements. All such changes may be published in provider newsletters, special mailings, and/or forms of online communications such as the Provider Resource Center.

In addition to the Highmark Provider Manual, please check the Provider Resource Center’s home page and its Latest Updates section often for policy and procedure updates. The Highmark Provider Manual is binding upon providers together with other administrative requirements (as defined or described in the applicable provider agreement).

1.1 How to Use this Manual

The Highmark Provider Manual is designed to be your primary reference guide to doing business with Highmark. It contains information specific to procedures required of all Highmark network participating providers — professional, facility, and ancillary — and is intended as a companion to other Highmark provider requirements, publications, and communications.

The Highmark Provider Manual is binding upon providers and may be supplemented or superseded, in whole or in part, by other Highmark guidance and/or requirements furnished or otherwise made available to providers.

Tips for Using This Manual

• Most recent updates: When changes are made to the Highmark Provider Manual, we will communicate those changes on our What’s New page.
• Resources for all Highmark service areas: Because the manual applies to all service areas in Delaware, New York, Pennsylvania, and West Virginia, only the Highmark Blue Shield brand will be referenced.
  
  • The What Is My Service Area? map can be used to help you determine the service area for your location.
  • The Quick Reference/Contact Guide contains contact information for all Highmark Provider Service Centers and Highmark Clinical Services.
• Information specific to a service area: For information that does not apply to all service areas, either separate links will be provided or the information will be designated for a specific area by the use of an icon indicating the specific state or states to which the information applies.

State Icons:

• Is the information applicable to facility or professional provider types? Most units of the manual contain information that would be applicable to all provider types. If a unit is specific to professionals or facilities only, it will be noted within the text of the unit.
• Organized by Chapters/Units: The manual is organized by chapters and units. Chapters and their titles are listed in the navigation menu on the left side of the manual webpage. You can click on the arrow to the right of the chapter name to expand the menu, revealing the units and the list of topics covered within that chapter. Click on a unit to access its content.
  
  • To collapse the chapter menu, click on the arrow to the right of the chapter name.
• Search: To make it easier to find answers, there is a search box located at the top of every page. Type a term or phrase into the search box to see where it can be found throughout the manual.
  
• Intended to be an online resource: Keeping the Highmark Provider Manual electronic allows us to provide you with the most up-to-date information. All revisions to the manual are controlled electronically. Paper copies, screen prints, and all alternate versions noted below are considered uncontrolled and should not be relied upon for any purpose, as they may not be the most recent revision.

Emailing the Manual

To email the manual, click the Share button at the top of the page, and then Copy Link. You can then paste the link in an email. 

Printing the Manual

• An entire version of the manual can be printed by clicking the print button at the top right of the page.

Note: Please review the disclaimer in Chapter 1, Unit 1: Introduction (Manual Purpose and History) regarding saved or printed versions of the Highmark Provider Manual.

1.1 About Highmark

In the 1930s, Highmark's predecessor companies were established to help individuals in the communities they served pay for hospital and medical services. Today, that remains our mission — to deliver high quality, accessible, understandable, and affordable experiences, outcomes, and solutions for our customers. It guides our actions throughout Highmark's businesses.

Highmark Inc. was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield and Blue Cross of Western Pennsylvania. Highmark Inc. and its health insurance subsidiaries and affiliates now operate health insurance plans in Delaware, New York, Pennsylvania, and West Virginia that serve millions of members as well as hundreds of thousands of additional Blue Plan members through the BlueCard® program:

• Highmark Blue Cross Blue Shield (PA) provides integrated Blue Cross and Blue Shield coverage throughout the 42 counties of western, north central, and northeastern Pennsylvania.
• Highmark Blue Shield (PA) serves the 21 counties of central Pennsylvania, 5 counties of southeastern Pennsylvania, and the Lehigh Valley. 
• Highmark Blue Cross Blue Shield (WV) serves the entire state of West Virginia.
• Highmark Blue Cross Blue Shield (DE) serves the entire state of Delaware.
• Highmark Blue Cross Blue Shield (WNY) serves 8 counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming.
• Highmark Blue Shield (NENY) serves 13 counties: Albany, Clinton, Columbia, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington.

Highmark Health, established in Pittsburgh in 2013, is a national health and wellness organization that employs approximately 40,000 people and serves nearly 50 million individuals in all 50 states and the District of Columbia.

Highmark Health is the parent company of Highmark Inc. and its subsidiaries and affiliates. It is also the parent company for Allegheny Health Network, an integrated health care delivery network, which provides health care delivery, research, medical education, and wellness services.

The company’s diversified businesses provide a spectrum of specialty products such as dental insurance, vision care, and supplemental health programs across the country, including more than 600 Visionworks optical retail stores.

1.1 Highmark Works With Health Care Providers

Highmark understands the tremendous value that physicians, facilities, and other health care professional and organizational providers bring to its organization and to its members. That is why Highmark is constantly striving to make its relationships stronger and better through:

• Enhancing electronic communications and the exchange of data through websites like Availity®;
• Collaborating with providers to implement programs that lead to better medical outcomes for our members; and
• Restructuring our processes to make them easier and more efficient.

At Highmark, physicians and other health care professionals play an important role in the company’s governance and policy making. Independent health care professionals are active in a variety of positions that influence the core of Highmark’s operations — they make up the majority of committees that help resolve claims disputes and promote the delivery of quality medical care to Highmark members.

Health care professionals are also involved at various key junctures during the development of Highmark’s Medical Policy — the guidelines used in our coverage and reimbursement determinations.

Board of Directors

The Board of Directors of Highmark Inc. includes health care professionals (referred to as “Professional Directors”) and representatives from customers and the community (referred to as “Lay Directors”). The Bylaws of the Corporation require that at least fifteen percent (15%) (or as near to that number as can reasonably be achieved) but not more than twenty-five percent (25%) of the Board of Directors be Professional Directors. The business and affairs of the Corporation are managed under the direction of the Board of Directors.

Highmark's Quality Program Committees

As a way for Highmark to promote objective and systematic monitoring, evaluation, and continuous quality improvement, various program committees have been established. Highmark’s Quality Program Committees are made up predominantly of health care professionals and established by Highmark’s Board of Directors. For additional information about these Quality Program Committees, please see the manual’s Chapter 5.6: Quality Management.

1.1 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, Highmark Care Benefits Inc., 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.

1.2 Variety of Informational Resources

1.2 Highmark Websites

1.2 Highmark Provider Directory

1.2 Provider Resource Center

1.2 Provider Newsletters

1.2 Special Bulletins

1.2 Join Our Mailing List

1.2 Provider Service Center

1.2 Contact Information

1.2 Mailing Addresses

1.2 Disclaimers

1.2 Variety of Informational Resources

Highmark is committed to providing timely and pertinent information about our policies and programs to the provider community. Highmark has a number of easy-to-use electronic sources of information as well as service representatives available by telephone.

Highmark’s Informational Public Websites:

• HighmarkHealth.org
• Highmark.com
• MyHighmark.com - member website for all Highmark regions

Highmark's Provider Resource Center (PRC) for all Service Areas is accessible from Highmark.com, MyHighmark.com, and Availity^®:

• Highmark Provider Resource Center (PRC)
  • The PRC website is your primary source for provider information from Highmark for all of our regions.

Newsletters for Professional and Facility Providers:

• Provider News
• Medical Policy Update

Additional Sources:

• News and Announcements via Highmark's Payer Spaces in Availity
• Special Bulletins
• Join Our Mailing List
• Provider Service Center

1.2 Highmark Websites

Highmark’s informational public websites cover all core business and subsidiary companies. They provide a broad range of information to customers, health care professionals, and the public.

To learn about Highmark’s history and access information about Highmark companies, subsidiaries, and affiliates, visit highmark.com. This website also provides you with information about Highmark’s community involvement, event sponsorships, and programs. In addition, you can learn about our Highmark Direct retail stores, access health and safety tips, and so much more. The public website for Highmark plans with service areas in Delaware, New York, Pennsylvania, and West Virginia can also be accessed from highmark.com.

Access to the Provider Resource Center is also available at highmark.com. Click on For Providers at the top of the screen.

The public website for Highmark Inc. service areas in Delaware, New York, Pennsylvania, and West Virginia is MyHighmark.com. This website provides information specific to individuals, members, employers, producers, and providers living in these locations. You can also access the Provider Resource Center from MyHighmark.com

When Highmark members have questions related to their coverage, your office may want to direct them to the appropriate public website for their service area. On each of these sites, members can find the following information and more:

Provider, Pharmacy, and Drug Information: By selecting the Find Doctor or Rx tab, members can access the Highmark Provider Directory and find information about participating doctors, hospitals, and other medical providers in their service area. In addition, this link allows them to search for participating pharmacies and also access drug formulary information.

Member Login: Members can register on this site for access to their secure account information. Once registered, members can log in to view their benefits and health and wellness information. They can also access their claim information and manage their health spending accounts.

Product Information: Individuals looking for insurance can learn about the Highmark products available in their service area by selecting the applicable tab: Individual and Family, Medicare, Employer, or Producer.

1.2 Highmark Provider Directory

The Highmark Provider Directory, located on each of our public websites, is a fast, easy way for our members to find providers near their homes or their workplace. And, it is a valuable tool that offers your current and potential patients important details about your practice, including office location, hours of operation, parking availability, and nearby public transit information.

The Centers for Medicare and Medicaid Services (CMS) requires Highmark to have the most current information on our network providers and also requires ongoing review of all physician information listed in the Provider Directory. The National Committee for Quality Assurance (NCQA) also requires the Provider Directory to include, and Highmark to confirm, the same physician information as for CMS, as well as the physician’s hospital affiliation. Hospital affiliation means the hospital(s) in Highmark’s networks where physicians have admitting or attending privileges.

Providers are required to review and update their information as soon as a change occurs. All data should be reviewed once a quarter, at a minimum, to ensure accuracy. If you determine that your information is inaccurate in the online directory, you can conveniently update the information online by accessing Provider Data Maintenance or Provider File Management (Delaware, Pennsylvania, and West Virginia only) through Availity.

Providers who do not verify or update their data in a timely manner will be removed from the Highmark Provider Directory. In addition, the provider’s status within Highmark’s networks may be impacted.

For providers in Delaware, Pennsylvania, and West Virginia: We encourage you to take advantage of one of the more unique features of our online directory — the ability to add your photograph. The inclusion of a photo helps to personalize your directory listing and can make it easier to market your practice to potential patients. Your photo can be easily uploaded through Provider File Management in Availity.

Providers acknowledge that the information listed in any Highmark Provider Directory, including, but not limited to, name, contact information, description of services, photographs, demographics, and other information, may also be listed in any Blue Cross Blue Shield Association (“BCBSA”) and/or other BCBSA independent licensee Plan provider directory(s), as determined by Highmark.

Please see Chapter 3, Unit 3: Professional Provider Guidelines for additional details of CMS requirements and on reporting changes.

1.2 Provider Resource Center

The Provider Resource Center (PRC) is a repository of pertinent reference materials. This website is specifically dedicated to providers and contains lots of helpful information and resources to assist in your daily interactions with Highmark members and with Highmark. We encourage you to bookmark the site and take advantage of this convenient reference resource.

The Provider Resource Center is available at highmark.com and MyHighmark.com. 

For your convenience, the Provider Resource Center is also available to you in Highmark's Payer Spaces in Availity. Additional information not accessible on the public websites is available in the Provider Resource Center via your secure Availity logon. 

1.2 Provider Newsletters

Highmark regularly releases publications as part of our commitment to keep the provider community informed. Some of the most important ways Highmark communicates with all providers is through our newsletters – Provider News and Medical Policy Update.

Provider News is a valuable resource for health care providers who participate in our networks. Published monthly on the last Monday of the month*, Provider News conveys important product, policy, and administrative information, including billing, claims, and program updates.

The publication also features the latest news, information, tips, and reminders about our products and services, as well as relevant interviews, articles, and stories, for health care professionals who serve Highmark members.

Regular topics include:

• New and Updated Reimbursement Policies
• Authorization Updates
• Staying Up to Date With the Highmark Provider Manual

*When a holiday falls on the last Monday of the month, Provider News will be published on the preceding Friday.

Current and past issues of Provider News are always available online on the Latest Updates page of the Provider Resource Center. 

Medical Policy Update is a monthly newsletter that provides information for most health care professionals and facilities participating in our networks. It focuses exclusively on upcoming medical policy and claims administration updates (including coding guidelines and procedure code revisions), and is the sole source for this information.

It is important for all participating providers and their office staffs to review each issue of Medical Policy Update. This publication serves as one of Highmark’s official notifications of new and revised policies and procedures. You can find current and past issues of Medical Policy Update on the Latest Updates page of the Provider Resource Center.

Distribution of all provider newsletters is primarily electronic. We publish all issues of the newsletters online in the Provider Resource Center on the Latest Updates page. Current and past issues of Provider News and Medical Policy Update are always available on the Provider Resource Center.

You may also sign up for electronic notification via email by clicking Join Our Mailing List in the top right corner of every page.

If you require a paper copy of the newsletter, please contact the Provider Service Center.

1.2 Special Bulletins

In addition to our regular publications, Highmark uses Special Bulletins to inform providers of changes to Highmark policies and procedures, updates to the formulary and authorization list, upcoming initiatives, etc. Special Bulletins are intended to be a companion to Highmark’s regularly scheduled periodicals.

Special Bulletins are used when we want to communicate information quickly, when the information is too complicated or lengthy to include in the newsletters, or when the information pertains to a limited group of providers or to a specific service area.

These communications from Highmark may be delivered to providers in any of the following formats:

• Online Communications
• Letters
• Brochures
• Fact Sheets
• Postcards
• Flyers included with checks and/or Explanation of Benefits

Because Special Bulletins contain important information about specific claims and coverage issues that could affect your practice, we hope you will take time to read them and retain them for future reference.

You can find current and past Special Bulletins on the Latest Updates page of the Provider Resource Center.

1.2 Join Our Mailing List

The Join Our Mailing List feature on the Provider Resource Center allows you to subscribe to electronic notification of various online publications and information updates. The latest Highmark news and updates arrive in your email inbox with timely, up-to-date information at your fingertips.

To subscribe to receive free email notifications with newly released publications or information updates, select Join Our Mailing List located in the top right corner of every page.

Enter the required information on the online form and select the applicable provider type – Professional Provider (837P and 1500 billers) and/or Facility/Institutional (837I and UB04 billers). Once you have completed the form, click on the Subscribe button at the bottom of the page. You will receive a confirmation message immediately when your subscription is successfully submitted.

The emails will be delivered to you from noreply.providers@highmark.com. To ensure delivery of the emails, please add the email address to your address book.

By subscribing, you agree to electronically receive administrative requirements that are legally binding upon contracted providers and upon Highmark. By doing this, you acknowledge that such communications and publications will be sent only by electronic means to the email address you provide. Please maintain such electronic publications in the event of future questions and to ensure such compliance. You may unsubscribe from this list at any time on future emails from Highmark.

1.2 Provider Service Center

Immediate answers to most inquiries can be found by using Availity^® - the preferred method for eligibility and benefit checks, prior authorization requests and inquiries, claims submission, and other transactions. For more complex issues or if Availity is unavailable, Provider Service Center representatives are available to answer questions and also provide information about Highmark programs.

Find the appropriate Provider Service Center for your region here.

When placing a call to Provider Service, please have all necessary information available including:

• Patient’s name, member ID, and group number;
• If available, the type of services and dates the services were performed;
• Claim number (taken from the Explanation of Benefits); and
• The provider’s name and provider number.

1.2 Contact Information

This section includes additional important telephone numbers, fax numbers, and other helpful contact information for all Highmark service areas.

The Contact Us page of the Provider Resource Center features the most frequently used telephone numbers for contacting Highmark, including Highmark's Provider Service Center and Highmark Clinical Services.

For assistance or information about health care topics or support by a health coach, encourage your patients to call the Blues on Call phone line:

• 888-BLUE-428 (888-258-3428)

If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 800-AVAILITY (282-4548). 

For more information, contact Availity.

Availity is the preferred method for submitting authorization requests. Contact Highmark Clinical Services for precertification/authorization inquiries that cannot be handled via Availity. Call the applicable number for your service area and/or provider type.

When Availity is not available and/or for medical management questions/issues that cannot be handled through Availity, Highmark's Behavioral Health Services can be reached by calling the applicable phone number for your service area.

To enroll in this free maternity education and support program, expectant mothers can call 866-918-5267.

To verify eligibility and benefits for BlueCard members, use one of the following options:

• Eligibility and Benefits Inquiry in Availity
• BlueCard eligibility telephone line: 800-676-BLUE (2583)
• HIPAA 270/271 electronic transaction

BlueCard participating physicians in other Blue Plan areas can be located by calling 800-810-BLUE (2583), or online at https://www.bcbs.com/.

The Highmark Caring Program in Pennsylvania assists children with chronic conditions and/or special health care needs and their families to gain needed services by providing family-centered, community-based care coordination.

• For questions regarding care coordination, call 866-823-0892

Highmark encourages providers to identify members who could benefit from coordinated case management services. Providers can initiate a referral for case management services by utilizing Availity.

If you received payments from more than one insurer and the combined payments exceed your claim charge, contact the Provider Service Center in your service area to speak to a representative.

Highmark utilizes ProView™, the online credentialing system developed by the Council for Affordable Healthcare (CAQH), for credentialing and recredentialing.

• https://proview.caqh.org
• CAQH Help Desk: 888-599-1771

If you would like to begin to submit claims electronically or need assistance with electronic claims submission, contact the Highmark EDI Operations support line by calling 800-992-0246.

Click on the applicable link to access the Highmark EDI Services website for your service area:

• Delaware
• New York
• Pennsylvania
• West Virginia

Highmark partners with eviCore Healthcare (“eviCore”) for several care management programs. These include the following programs (may differ by Highmark region):

• Laboratory Management Program
• Radiation Therapy Authorization Program

Although authorization requests for these programs can be submitted through the provider portal, there may be times when it is necessary to contact eviCore by phone at 888-564-5492.

Evolent manages medical and radiation oncology authorization requests for some Highmark members. Highmark’s collaboration with Evolent is part of our oncology value-based care strategy, aiming to improve outcomes and streamline the authorization process.

For questions related to Evolent, email providertraining@evolent.com or contact Evolent authorization support at 888-999-7713 Monday – Friday.

Contact the Federal Employee Program (FEP) Provider Service Department by calling the applicable phone number for your service area:

• Delaware: 800-721-8005
• New York: 800-234-6008
• Pennsylvania: 866-763-3608
• West Virginia: 800-535-5266

Hours of availability are 8 a.m. to 12 p.m. and 1 p.m. to 5 p.m. EST, Monday through Friday.

Note: Eligibility and benefits can be verified through Availity for FEP members residing in Delaware, New York, Pennsylvania, and West Virginia.

For claims that cannot be submitted electronically, they can be mailed to the appropriate claims address for the member's service area which can be found later in this unit under Mailing Addresses.

If you suspect fraud, contact your local Financial Investigations and Provider Review (FIPR) Department within Highmark.

Delaware and Pennsylvania:

• P.O. Box 890138 Camp Hill, PA 17089-0138
• Phone: 800-438-2478 or 800-352-9100
• Fax: 717-635-4590

New York:

• Highmark Blue Cross Blue Shield (WNY):
  • 1 Seneca Street, Ste 3400, Buffalo, NY 14203
  • Phone: 800-333-8451
  • Fax: 717-635-4590

• Highmark Blue Shield (NENY):
  • 40 Century Drive, Latham, NY 12110
  • Phone: 800-314-0025
  • Fax: 717-635-4590

West Virginia:

• 614 Market Street, P.O. Box 1948, Parkersburg, WV 26102
• Phone: 800-788-5661
• Fax: 717-635-4590

Due to the nature of these investigations, every effort will be made to keep information confidential. Report suspected health care fraud anonymously via the above phone numbers or the Health Care Fraud Form.

For information on Health Options, Highmark Delaware’s managed care organization serving Delaware Medicaid recipients, see the Health Options Provider Manual, which is accessible on the website linked below.

• Health Options Provider Services: 844-325-6252
• Authorizations: 844-325-6254
• Health Options website: http://www.highmarkhealthoptions.com/

To obtain an NPI:

• Website: https://nppes.cms.hhs.gov; or
• Phone: 800-465-3203 (TTY: 800-692-2326)

For spending account questions or issues in Pennsylvania and West Virginia, call the dedicated Provider Spending Account Information Line at 800-652-9478.

For spending account questions or issues in Delaware, contact Provider Service at 800-346-6262.

Delaware and Pennsylvania:

• Novitas Solutions, Inc.
• Website: www.novitas-solutions.com
• Medicare Part A and B Provider Inquiries: 877-235-8073 (TTY: 877-235-8051)
• Hours: 8 a.m. to 4 p.m. EST, Monday through Friday.

West Virginia:

• Palmetto GBA
• Website: www.palmettogba.com
• Medicare Part A and B Inquiries: 855-696-0705 (TDD: 866-830-3188)
• Hours: 8 a.m. to 4:30 p.m. EST, Monday through Friday.
  

If you have questions about Form 1099-MISC issues, please call 866-425-8275, or send via email to 1099inquiry@highmark.com.

1.2 Mailing Addresses

Electronic claims are convenient, confidential, and operational around the clock. Highmark’s claim processing system places a higher priority on claims filed electronically. And we offer options for HIPAA-approved claims submission via Availity Essentials and Highmark Electronic Data Interchange (EDI).

If you are not submitting claims electronically, use the tables below to determine the correct mailing address(es) for your region.

Highmark Blue Cross Blue Shield (DE)

Highmark Blue Cross Blue Shield (WPA/NEPA)

Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY)

Highmark Blue Cross Blue Shield (WV)

Highmark Blue Shield (CPA/SEPA)

If you are considering a move from paper claim submissions, see the manual’s Chapter 1, Unit 3: Electronic Solutions — EDI and Availity and Chapter 6, Unit 2: Electronic Claim Submission.

Important: Only Original Paper Claim Forms Accepted

Highmark will accept and process only original red 1500/version 02/12 and UB-04 claim forms. Photocopies or outdated versions of the forms will be returned to the provider. The provider will need to resubmit the returned claims on the appropriate form.

Highmark utilizes the Optical Character Recognition (OCR) scanning system to ensure accurate and efficient processing of paper claims. The OCR Scanner is programmed to read only the original red 02/12 version of the 1500 form and the original UB-04 institutional claim form.

Highmark provides recommended forms that providers may use when communicating with Highmark, Highmark members, or other providers in the network. The forms are readily available online in the Forms section of the Provider Resource Center (found under Resources and Education in the main menu).

If you require forms that are not available on the Provider Resource Center, forms may be ordered by writing to:

Highmark Shipping Control
P.O. Box 890089
Camp Hill, PA 17089-0089

Please include the form number and title, quantity, and shipping address.

To obtain a copy of Premier Blue Shield allowances for the most frequently reported codes for your specialty or a copy of your Highmark Blue Shield Usual, Customary, and Reasonable (UCR) profile, send a letter of request to:

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

Include your Highmark provider ID number, full name, address, and indicate whether you are requesting your UCR profile, Premier Blue Shield allowances, or both. This information is also available via Availity for those Availity-enabled offices.

Availity Essentials is the preferred method for submitting pre-service and retrospective reviews. If you are not submitting requests electronically, use the table below to determine the correct mailing address for your region.

These postal addresses are to be used solely for overpayments from:

• Health Savings Accounts (HSAs)
• Health Reimbursement Accounts (HRAs)
• Flexible Spending Accounts (FSAs)

1.2 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, Highmark Care Benefits Inc., 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.

1.3 Introduction

1.3 Highmark Electronic Transaction Requirements

1.3 Electronic Data Interchange (EDI)

1.3 About Trading Partners

1.3 Getting Started With Electronic Claim Submission

1.3 Availity Automated Inquiries and Transactions

1.3 Real-Time Capabilities

1.3 Disclaimers

1.3 Introduction

Highmark places a high priority on electronic exchange of information and electronic claims filing. This process is more efficient and cost-effective than conventional means — benefiting health care facilities, professionals, members, and insurers.

The company’s electronic commerce division, Electronic Data Interchange (EDI) Services, provides a host of services that make filing claims and accessing information faster and easier. These include:

• A claims clearinghouse where you can electronically submit claims and inquiries for Highmark
• Convenient technical support through a toll-free hotline
• Information on getting started in electronic claims filing

In addition, Highmark's provider portal, Availity, is available at no cost to all participating providers. Availity is an internet-based application for providers to streamline data exchanges between their offices and health insurance companies. Through Availity, providers are able to submit claims through the HIPAA-compliant claim submission function. This provider portal also allows providers to verify enrollment, eligibility, benefits, claim status, and much more.

1.3 Highmark Electronic Transaction Requirements

In support of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, Highmark has taken steps to eliminate paper transactions with our contracted providers.

Due to their inherent speed and cost-effectiveness, electronic and online communications are integral in today’s business world and Highmark requires that all network providers participate in electronic programs sponsored or utilized by Highmark now or in the future.

Enrollment in Availity and Electronic Funds Transfer (EFT)

All Highmark network participating providers are required to enroll in Availity Essentials^® and EFT via PNC ECHO. Once you enroll, you will have access to paperless Explanation of Benefits (EOB) statements from both Availity and PNC ECHO.

Availity integrates all insurer-provider transactions into one system (e.g., eligibility and benefit inquiries, claim status inquiries, claim submission, authorization requests, etc.). This service is available at no cost to Highmark network participating providers.

Participating providers are also required to enroll in EFT via PNC ECHO. EFT is a secure process that directs Highmark claim payments to the provider’s checking or savings account as directed by your office. Payments are typically in the designated bank account by Wednesday of each week.

Paperless EOBs

Paperless EOB statements reduce the amount of paper flowing into the provider’s office. EOBs are available for viewing on Monday morning via Availity — which is two days earlier than receiving them by mail. This information is also available for viewing within PNC’s Healthcare’s ECHO Health platform.

Important: New York Providers

Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) providers should no longer use Administrative Services of Kansas (ASK) for electronic claim submissions. New York providers who need to transition electronic claim submissions from ASK to Highmark's Electronic Data Interchange (EDI) should contact Highmark-EDI Operations at 800-992-0246 or visit our EDI Trading Partner Business Center site to initiate this change. Electronic claims for all New York providers must be submitted to Highmark's EDI by September 2026.

Once an EFT payment is received, providers will be able to view EFT payments via Availity or the ECHO provider payments system. In addition, Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) providers may still opt in to paper Explanation of Benefits.

Enrolling in EFT

After becoming Availity-enabled, providers must also enroll in Electronic Funds Transfer (EFT). Claims payments are generated from PNC-ECHO Health Trust. Electronic Remittance Advices (ERAs) are distributed using the following ECHO Payer IDs:

• Delaware, Pennsylvania, and West Virginia: 58379
• New York: 55204

Providers may elect to receive EFT only or 835/EFT through the ECHO Health platform. To sign up to receive EFT on the ECHO Health platform, providers must visit their EFT/ERA enrollment page.

Virtual Credit Cards: Providers who have not registered to accept payments electronically will receive virtual credit card payments with their EOBs. Offices opted in to virtual credit cards (VCC) will receive notification for each payment via mail or fax, which will include a unique virtual credit card number and instructions for processing. Providers may opt out of VCC by visiting/calling ECHO Health at 800-890-4124.

Additional Payment Options: ECHO also offers payments via Medical Payment Exchange (delivers payments and EOBs electronically and gives providers the option to print a check at no cost, receive a virtual card payment, or enroll for EFT) or paper check. Explore more details about these options on ECHO Health’s platform.

Once providers are enrolled and start receiving EFT payments, they will no longer receive paper EOB statements or remittances. Providers will still be able to view the claims status and a copy of the EOB through Highmark’s provider portal, Availity. However, providers will need to visit ECHO Health’s platform to manage/change payment information.

Availity Support

With Availity, an individual in your office or facility serves as the administrator. That individual can register with Availity online. The office administrator can begin the registration process on the Register and Get Started with Availity Essentials webpage. After registering an organization, the administrator can add other users from the administrator’s organization.

To learn more about registering and getting started with Availity, go to the Register and Get Started with Availity Essentials webpage.

If you need assistance with an existing account or have started the registration process and are experiencing issues, you can call 800-AVAILITY (282-4548).

For more information about contacting Availity, click here.

1.3 Electronic Data Interchange (EDI)

Everyone has a stake in health care cost containment. Health care professionals, patients, insurance companies, and state and federal government are all affected by the high price of maintaining good health. Fortunately, technology can help simplify business operations and thus cut costs.

Due to their inherent speed and cost-effectiveness, electronic transactions and online communications are integral to today’s business world. Electronic transactions between health care professionals and insurers are essential to maintain efficiency. EDI makes electronic communications a viable method of streamlining claims processing and eliminating wasted time and money.

Highmark provides you the convenience and cost savings of electronic data interchange through various means. Some of the most common forms of provider electronic exchanges with Highmark include streamlined claims filing, acknowledgement information about your claims, inquiry features, and information retrieval.

Highmark EDI Services

Highmark EDI Services supports a variety of HIPAA-compliant electronic inquiry and claims transactions including, but not limited to:

To find out more about the EDI services available to Highmark Trading Partners in support of their electronic business activities, visit the Highmark EDI Services website. The site provides current information about transaction specifications, Trading Partner requirements, and enrollment applications.

Click on the applicable link to access the Highmark EDI Services website directly:

• Delaware
• New York
• Pennsylvania
• West Virginia

1.3 About Trading Partners

A trading partner is an entity that conducts business electronically with Highmark. Providers, clearinghouses/billing services, and software vendors are the most common types of trading partners who enter into agreements with Highmark.

Before a provider, clearinghouse/billing service, or software vendor can begin to do business electronically with Highmark, an agreement must be executed. The agreement explains both Highmark's and the Trading Partner’s obligations as well as defines the terms, indemnification, and compliance with privacy standards. It further establishes the legal relationship and requirements within Highmark.

To view the Provider Trading Partner Agreement in its entirety, click on the applicable link below to access the site directly:

• Delaware
• New York
• Pennsylvania
• West Virginia

A provider is a health care professional, institution, or organization in whose name the bill is submitted and to whom payment should be made. A clearinghouse, or billing service, is an entity which submits claims or other transactions on behalf of professional or institutional providers.

• Providers doing their own electronic billing using a vendor software package must apply for their own Trading Partner number.
• Providers using a billing service or clearinghouse to conduct electronic billing must be affiliated with the Trading Partner number of the billing service or clearinghouse.
• Billing services and clearinghouses must obtain their own Trading Partner numbers for conducting electronic business with Highmark. In addition, customers (providers) must be affiliated to their Trading Partner number(s).

Complete an EDI Transaction Application to request a Trading Partner ID. The type of application depends on the business functions you will be performing. All applicants will be required to review and accept the terms of Highmark’s EDI Trading Partner Agreement. 

To complete an application, click on the applicable link below to access the site directly: 

• Delaware
• New York
• Pennsylvania
• West Virginia

Your Trading Partner Profile at Highmark includes many facts about your practice or facility, such as:

• Practice or facility name
• Address (both physical locations and where checks should be sent)
• National Provider Identifier (NPI)
• Individual Practitioners who submit claims under a practice’s Billing Provider Number
• NPI for each Practitioner

Highmark relies on Trading Partner and vendor contact information in case there are technical and/or business issues that require communication.

Changes to provider or trading partner information can affect how claims are received or processed by Highmark. We recommend that you remain diligent about reporting all changes within your practice as quickly as possible.

Electronic transaction exchanges with Highmark can be affected by certain changes made within your practice. In some cases, separate notification about your changes must be submitted to EDI Operations.

If a new provider is added to your staff who will receive payment directly from Highmark, you must add this provider to your Trading Partner number. If you do not complete this step, you will experience problems with receiving payment for this provider’s services.

If you need to report changes to Highmark, a specific request to change your Trading Partner information must be submitted. The forms can be found on the EDI website. You can access the website by selecting Electronic Data Interchange (EDI) Services by clicking the applicable link below: 

• Delaware
• New York
• Pennsylvania
• West Virginia

If after visiting the EDI website you still have questions about your Trading Partner Profile, call EDI Operations at 800-992-0246.

1.3 Getting Started with Electronic Claim Submission

Practice Management System Vendor: Purchase a complete system from a reputable vendor. Complete system solutions typically include the hardware (personal computer, monitor, modem, and printer) and the software which includes electronic claims submission and possibly accounts receivable posting capabilities. Terms and conditions of each system vary from vendor to vendor.

Clearinghouse or Billing Service: Health care professionals can outsource their electronic claim submissions to private billing services and/or a clearinghouse. Terms and conditions vary from billing service to billing service and clearinghouse to clearinghouse.

If you will be submitting directly to any of the Highmark payers, enroll online by visiting the Electronic Data Interchange (EDI) Services website by clicking the applicable link below: 

• Delaware
• New York
• Pennsylvania
• West Virginia

Upon receiving your completed application, EDI Operations will process your request and verify that you have a valid National Provider Identifier (NPI). A Trading Partner ID will then be assigned to you.

Within 5 to 10 business days, you should receive a secure email listing your assigned Trading Partner number, login identification and password, and the transmission telephone number.

If you are billing through a Trading Partner, clearinghouse, or billing service, check with them regarding the registration process to affiliate your NPI to their Trading Partner number.

1.3 Availity Automated Inquiries and Transactions

Availity Essentials gives users real-time access to Highmark's membership, claims, and provider and payment systems, making your job easier.

Availity provides access to Highmark’s tools for real-time claim estimation and adjudication. Our Provider Resource Center is also accessible through Availity.

Availity is the preferred Highmark tool for inquiring about member information. Availity-enabled providers are expected to use this tool for all routine eligibility, benefit, and claim status inquiries. Practices must use Availity for routine inquiries that can easily be answered online. The expertise of the Provider Service staff will remain available for non-routine inquiries that require analysis and/or research.

1.3 Real-Time Capabilities

Highmark’s real-time tools are available to all Availity-enabled contracted providers and to providers who submit electronic claims through a practice management system.

These primary real-time capabilities include:

• Real-Time Provider Estimation allows providers to submit a claim (837) for a proposed service and receive a response (835) in real-time. The 835 response estimates the member liability based on the current point in time and the data submitted for the proposed service. This capability allows providers to identify potential member liability and set patient financial expectations prior to a service. This can also be used at the time of service to actually identify and discuss payment arrangements or collect member liability at the point of service.
• Real-Time Claims Adjudication allows providers to submit a claim (837) that is adjudicated in real-time and receive a response (835) at the point of service. This capability enables providers to accurately identify and discuss payment arrangements or collect member liability based on the finalized claim adjudication results.

Other supporting capabilities related to real-time claim adjudication include:

• Accelerated Payment
• Accelerated Member Explanation of Benefits (EOB) on the Highmark Member portal

These real-time capabilities give providers the ability to discuss member financial liability with patients when services are scheduled or provided. Providers could also collect applicable payment or make payment arrangements at the time of services, if they wish to do so.

Providers who are interested in integrating real-time capabilities within their practice management system should discuss this functionality with their software vendors. They should also review the Electronic Data Interchange (EDI) transaction and connectivity specifications in the Resources section on the EDI website.

• Delaware
• New York
• Pennsylvania
• West Virginia

1.3 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, Highmark Care Benefits Inc., 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.

1.4 Unit Definitions

1.4 Identifying Highmark Members

1.4 Member Identification Cards

1.4 Verifying Eligibility and Benefits

1.4 Dependent Eligibility

1.4 Confidentiality of Member Information

1.4 Advising Members of Treatment Options

1.4 Member Access to Physicians and Facilities

1.4 Communication Aids and Services

1.4 Administrative Fee Collection Guidelines

1.4 After-Hours Physician Accessibility Study

1.4 Disclaimers

1.4 Unit Definitions

Member

A member is an individual who is enrolled in a health plan and who meets the eligibility requirements of the program.

Subscriber

A subscriber is a member whose employment or other status, except for family dependency, is the basis for eligibility for enrollment in a program.

Dependent

A dependent is any member of a subscriber’s family who meets the applicable eligibility requirements and is enrolled in a program.

Managed Care Plans

Managed care plans are delivered through a provider network. Under some plans, members may visit providers in or out-of-network; however, the highest level of benefits are paid for visits to in-network providers.

Managed care plans include:

• Health Maintenance Organizations (HMOs);
• Point of Service (POS);
• Open Access;
• Preferred Provider Organizations (PPOs); and
• Exclusive Provider Organizations (EPOs).

Indemnity Plans

Traditional indemnity plans are sometimes referred to as fee-for-service plans in that they pay a set amount per health care service performed. It gives members the widest choice of physicians and services through participating providers. Generally, these plans are subject to a deductible and coinsurance. 

1.4 Identifying Highmark Members

A Highmark member can be easily identified by the information on his or her identification (ID) card. Always ask to see the ID card upon the patient’s first visit. On subsequent visits, ask the patient if he or she has had a change in health insurance. A patient’s insurance information can change at any time and incorrect information can result in delayed claim payment. Although the ID card provides enrollment information for a Highmark member, it is recommended that you always confirm eligibility for the date of service through Availity, Highmark’s internet-based inquiry system, or by performing an electronic HIPAA 270 Eligibility/Benefit Inquiry transaction.

Member ID Cards

All Highmark members receive an identification card so you can easily identify them and have essential information to help you understand their coverage. The identification cards may have slight variations depending upon the type of program and the location of the Blue Plan through which members are enrolled. There may also be some small variances on cards of each employer group. Practices with the fewest claim submission errors generally require the member to show the current ID card with each visit and verify eligibility on every visit/service. This is why it is important to check the member’s identification card prior to each visit or service you provide.

Generally, the identification card includes the following information:

• Subscriber’s name;
• Dependent’s name, if applicable;
• Member’s Unique Member Identifier (UMI), or “Member ID,” which includes a 3-character prefix and a 12-digit identification number;
• Group number – a series of alphabetical and numeric characters assigned to employment groups, professional associations, and direct payment programs;
• Plan Code – three digits that identify the Blue Plan through which the member is enrolled;
• Type of agreement – a brief description of the type of agreements and coverage of the member (not all identification cards have this information); and
• BlueCard® – all BlueCard members can be identified by a 3-character prefix preceding the member identification number on their identification card. Always report the 3-character prefix from any ID card. 

Members may have more than one identification card if they are covered under more than one plan. Please verify the correct prefix and identification number for reporting services.

Prefix

The 3-character prefix at the beginning of the member’s identification number is the key element used to identify and correctly route claims. The Blue Cross Blue Shield Association (BCBSA) issues “alphanumeric prefixes” to Blue Plans.

Occasionally, Highmark will assign new alphanumeric prefixes when new groups are created. Please be aware that you may be seeing local Highmark members with valid alphanumeric prefixes on their Member ID cards. Since existing prefixes will not change, you will also continue to see the familiar “alpha prefixes.”

Please see the manual’s Chapter 2 Unit 6: The BlueCard Program, section titled “How to Identify BlueCard Members,” for more information on the BCBSA 3-character prefixes that can be either three alpha characters or a combination of alpha and numeric characters.

Important! Medicare Advantage members retain their Medicare cards even after they begin coverage under Highmark Medicare Advantage products. You should always ask Medicare-eligible patients if they have joined a Highmark Medicare Advantage plan and, if they have, request their Highmark Medicare Advantage ID card. If a new Highmark member comes to the office and has not yet received an identification card, they may present an enrollment form or, for Medicare Advantage, a letter of confirmation in lieu of an ID card.

1.4 Member Identification Cards

Identification cards are issued to all Highmark subscribers and their dependents. The ID cards feature a simplified format with key information regarding benefits and eligibility. Blue Cross and Blue Shield Association (BCBSA) regulations require subscriber identification cards of all Blue Plans to follow the same format. Highmark’s member identification cards satisfy BCBSA requirements. 

The BCBSA required design features of the identification card include:

• Background color: The background of the card must be white only.
• Easily identifiable standardized “zones” for display of information: The front of the card features eight easily identifiable zones, while the back is divided into five zones. Horizontal black lines mark divisions among zones.
• Blue Plan name and logo: The Highmark company name and logo appears on the left side of the top section of the ID card.
• Member name and Member ID: The member name followed by the member identification number will always appear below the Highmark logo.
• Name of the product under which the member has coverage: The member’s Highmark product is displayed on the right side of the top section of the ID card. An employer group name may also appear here.
• Blue Cross Blue Shield Association’s “suitcase” logo: The suitcase logo, identifying BlueCard participation, appears in the lower right corner.
• Prescription Drug Program group number: This number appears on the front of the card, in the third zone on the left, along with the member’s medical Group Number and the Blue Cross/Blue Shield Plan Area Code.
• PCP: The PCP name will appear if a valid PCP has been chosen.
• ID cards for dependents: Both the subscriber and dependent information appear on a dependent’s ID card. Subscriber information is on the left side of the front of the card while dependent information is on the right. 
• Copays: Copays - such as PCP, Office Visit, Specialist Visit, Emergency Room - may appear if applicable.
• Coverage effective date information on individual products (“Direct Pay”): This information is no longer provided on the ID card for members with employer-sponsored coverage.
• Back of card: The applicable Blue Cross and/or Blue Shield symbols will be at the top. The internet address of the Blue Plan must appear in bold-face type on the right side of the top section of the ID card, with all relevant telephone numbers in bold-face type below it.

The Highmark company name/logo will always appear on the left side of the top section of the front of the ID card. Other areas will be populated as follows (numbers correspond to numbered areas on the sample ID card above):

1. Licensed Product Name: The product name, such as PPO Blue or Community Blue PPO, will appear here and will help you determine which network rules to follow.
2. Member Identification Information:
   1. The Member Name is the individual, or “subscriber,” under whose name the coverage was established.
   2. The member’s identification number, or Member ID,” includes the 3-character prefix that varies by employer group or account (not applicable to Medicare Advantage products).
3. Dependent and PCP Information (if applicable):
   1. Both the subscriber and dependent information will appear on a dependent’s ID card, with the dependent’s name in this section on the right. Always verify that you have the card that corresponds with your patient and not that of another family member/dependent.
   2. The PCP’s name will appear here if a valid PCP is chosen.
4. Medical and Pharmacy Claims Processing Information:
   1. The group number identifies the member’s medical group.
   2. The 3-digit Plan Codes identify the corresponding Blue Plan.
   3. The RxGrp/RxBIN numbers identify the applicable prescription coverage information.
5. Member Cost Sharing:
   1. PCP, specialist office, office visit, and/or emergency room copayments may be listed. Specialist copays may not be the same for behavioral health care services, therapies, or diagnostic services; those copayments may be found via Availity or by calling the phone number on the back of the ID card.
   2. Pharmacy copayments are not listed. Participating pharmacies can verify copayment amounts online.
6. Additional Coverage Information: Other coverage information may be indicated here, such as hearing, vision, and/or dental.
7. Suitcase Logo: Indicates a member of the BlueCard® program. For more information about BlueCard, please refer to Chapter 2 Unit 6: The BlueCard Program of the Highmark Provider Manual.
8. Rx Logo: This will be on the ID card whenever a Highmark prescription drug program is included.

Back of the Member ID Card

The back of the member’s identification card contains information mainly for the member’s use. The information may differ based on the product and may include, but is not limited to, the information outlined below.

1. Plan Specific Information: Benefit and administrative information specific to Highmark and/or the member’s coverage such as advising the member how to receive the highest level of benefits by obtaining care from an in-network provider.
2. Plan Website: Identifies the Blue Plan’s website address to access Plan information online.
3. Plan Contact Information:
   1. Blues On Call phone number to call for health education and support services.
   2. Member Service phone number for members to call Highmark with questions about benefits, claims, etc.
   3. Additional telephone numbers for members to receive assistance in obtaining admission to non-participating hospitals, facilities, mental health, and substance abuse treatment programs, etc.
4. Claim Submission Information and Independent Licensee Disclosure: Lists addresses for member submitted claims. The “tag line” identifying Highmark as an independent licensee of the Blue Cross Blue Shield Association will be found here.
5. Pharmacy Benefits Administrator and Logo: The name and logo of the pharmacy benefits administrator may appear here, if applicable.

Digital Member ID Cards

Highmark members can access digital versions of their ID cards through the member portal. These digital cards are equivalent to physical cards and provide real-time eligibility and benefits information. For proof of coverage, members may present these cards on their phones. Members also have the option to download and share them via email or text. For provider convenience, offices can print or save digital ID cards as PDFs in Availity. Digital ID cards should always be honored for appointments or services. 

Examples of Highmark Member ID Cards

The Blue Cross and Blue Shield Association (BCBSA) regulations require that all subscriber identification cards be in the requisite format. Therefore, you should accept only those cards in the design format described within this unit. Click on the link for your region to view samples of Highmark’s ID cards:

• Highmark Blue Cross Blue Shield (DE) ID Card Samples
  
• Highmark Blue Cross Blue Shield (WNY) ID Card Samples
  
• Highmark Blue Cross Blue Shield (WPA/NEPA) ID Card Samples
• Highmark Blue Cross Blue Shield (WV) ID Card Samples
• Highmark Blue Shield (CPA/SEPA) ID Card Samples
• Highmark Blue Shield (NENY) ID Card Samples

1.4 Verifying Eligibility and Benefits

It is the responsibility of the provider to verify that the member’s benefit plan provides the appropriate benefits for the anticipated date of service prior to rendering service. Highmark recommends that providers confirm a member’s eligibility on the anticipated date of service or one business day prior to the anticipated date of service. You can verify a Highmark member’s coverage by using Availity^® or performing an electronic HIPAA 270 Eligibility/Benefit Inquiry transaction, or by calling the Provider Service Center.

HIPAA 270 Eligibility and Benefit Inquiry Transaction

Highmark’s Electronic Data Interchange (EDI) transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Eligibility and benefits for Highmark members can be verified by performing an electronic HIPAA 270 Eligibility/Benefit Inquiry transaction. For more information on electronic connectivity with Highmark, click the applicable link below:

• Delaware
• New York
• Pennsylvania
• West Virginia

You may contact the EDI Operations support line at 800-992-0246.

Provider Service Center

For those providers who are not Availity-enabled or without electronic capabilities, Provider Service Center representatives are available to provide information about Highmark member eligibility and benefits. For Provider Service Center contact information in your region, see the manual’s Chapter 1, Unit 2: Online Resources and Contact Information or go to the Contact Us page.

Verifying Eligibility For Bluecard^® Members

To verify eligibility for BlueCard^® members, please use Availity or call 800-676-BLUE. For additional information about BlueCard, please see the manual’s Chapter 2 Unit 6: The BlueCard Program.

Additional information is also available in the BlueCard Information Center on the Provider Resource Center – select Provider Network, then Inter-Plan Programs from the main menu at the top of the page.

Limitations

It is a member’s responsibility to timely notify his/her employer of eligibility changes (e.g., divorce, loss of student status) and the group’s responsibility to notify Highmark timely of such changes. Highmark cannot accurately verify eligibility if the member or group does not timely notify us of eligibility changes.

On rare occasions, an insured group may be terminated retroactively by Highmark for non-payment of premiums (groups are allowed at least a 30 day grace period for payment of premiums). Similarly, a self-funded group may be terminated retroactively for non-payment of claims or administrative expenses. In both cases, eligibility of the members is terminated as of the date the group is terminated. In all cases, a provider may bill the patient directly for the cost of any services provided after the effective date of termination. Also, Highmark may terminate an individual member retroactive to the last day of the month the individual was eligible.

1.4 Dependent Eligibility

Health Care Reform (HCR)

The Patient Protection and Affordable Care Act (PPACA) is a federal law, enacted on March 23, 2010, that makes health insurance coverage available to all Americans. The provisions in the new law are collectively referred to as Health Care Reform (HCR).

One of the many provisions of the law requires that all health benefit plans provide coverage for dependents on their parents’ policy up to age 26 years. All health plans (individual and group health insurance, including self-funded plans) that cover children as dependents must continue to make that coverage available until the adult dependent reaches age 26 regardless of whether the adult dependent is married or a student.

ACT 4 of 2009: Health Insurance Coverage for Adult Children

Pennsylvania Act 4 of 2009, Health Insurance Coverage for Adult Children, expands health insurance coverage for children of insured parents. It allows adults up to age thirty (30), under certain conditions, to remain covered by their parents’ health insurance. It is a state mandate that gives employer groups the option to extend health insurance coverage to the children of their employees up to and including age twenty-nine (29) years.

While Act 4 provides an opportunity for many young adults to obtain health insurance, it does not require that employers offer coverage to adult children of their employees. Act 4 does require licensed insurers to offer employer groups this option at the insured employee’s expense.

Verifying Dependent Eligibility

The changes in dependent eligibility will be relatively seamless for providers. Adult dependents with coverage under their parents’ agreement will have a Highmark ID card providing the applicable member identification number.

As always, request the member’s ID card on each visit, and then verify coverage and benefits through the Availity Eligibility and Benefits function. Availity is the preferred tool for inquiring about Highmark member information. Availity-enabled providers are expected to use this tool for all routine eligibility, benefit, and claim status inquiries. For those providers not Availity-enabled, eligibility can be verified by submitting a HIPAA 270 Eligibility/Benefit Inquiry transaction or by calling the Provider Service Center.

Please see Chapter 1, Unit 2: Online Resources and Contact Information for more information on contacting the Provider Service Center in your region.

1.4 Confidentiality of Member Information

Confidentiality Policy

In accordance with the highest standards of professionalism, and as a requirement of all provider contracts, providers are obligated to protect the personal health information of the Highmark members they treat from unauthorized or inappropriate use.

Member Rights and Responsibilities

Highmark treats members in a manner that respects their rights and will clearly communicate Highmark’s expectations of our member responsibilities. Please see Chapter 1 Unit 5: Member Rights and Responsibilities to review our members’ rights and responsibilities.

Normal Business Operation

The Health Insurance Portability and Accountability (HIPAA) Privacy Rule generally allows Highmark to use and disclose members’ protected health information (PHI) for treatment, payment, and health care operations. Examples include:

• Claims management
• Certain types of routine audits by Highmark’s group customers
• Coordination of care
• Quality assessment and measurement
• Case management
• Utilization review
• Performance measurement
• Customer service
• Credentialing
• Medical review
• Underwriting

Release of Information for Non-Routine Use

If member information is needed for reasons other than those listed above, Highmark must generally obtain the member’s consent via an Authorization for Disclosure form.

If a member is unable to give informed consent, Highmark has a process to obtain this permission through a parent or legal guardian signature, signature by next of kin, or attorney-in-fact. The member has the right to limit the purposes for which the information can be used and all concerned are obligated to respect that expressed limitation.

Internal and External Controls

Members of Highmark products benefit from the many safeguards Highmark has in place to protect the use of data it maintains. This includes comprehensive privacy and security training of members of Highmark’s workforce; requiring Highmark employees to sign statements in which they agree to protect members’ confidentiality; using computer passwords to limit access to members’ PHI; and including confidentiality language in our contracts with doctors, hospitals, vendors, and other health care providers.

Providers’ Responsibility to Protect PHI

Members must not be interviewed about medical, financial, or other private matters within the hearing range of other patients. Practitioners must have procedures in place for informed consent and the storage and protection of medical records. Highmark will verify that these policies/procedures are in place as part of the onsite review process, when applicable.

IMPORTANT: Part 2 Substance Use Disorder Providers Must Obtain Patient Consent Before Claim Submission

If a provider, whether in-network or out of network, treats or diagnoses patients for Substance Use Disorders or refers patients for treatment of Substance Use Disorders and is subject to the Confidentiality of Substance Use Disorder Patient Records Rule (42 C.F.R. Part 2) as a Part 2 Program, payment of any claim a provider submits for such services is contingent upon compliance with the following requirements. “Part 2 Program,” “Part 2 Records,” and “Substance Use Disorder” shall have the meanings provided in 42 C.F.R. § 2.11. 

Provider shall comply with the following requirements with respect to any claim or other communication it submits to Highmark that contains Part 2 Records:

• A provider is prohibited by law from disclosing Part 2 Records, including but not limited to submitting claims to the health plan, without obtaining patient consent.
• By submitting any claim (or other record) that contains Part 2 Records, the provider certifies that patient consent has been obtained and includes all required elements required by law.
• Providers may use this Authorization of Disclosure form or their own form that is compliant with Part 2.

Physicians and all other Highmark participating providers are also bound by their contracts to comply with all state and federal laws protecting the privacy of members’ personal health information.

Processes to Protect Confidentiality of Provider and Member Information and Medical Records

• Provider Profiling Data and Member information will be held confidential and will be limited to the Clinical Services staff involved in the initiatives.
• Requests for provider/member information must be in writing.
• Requests for provider information from outside sources, which may include, but not limited to, the New York State Department of Health and/or attorneys require a subpoena and accompanying court order be submitted to the Health Plan Legal Department. For release of drug and alcohol treatment records covered by 42 CFR Part 2, a subpoena by itself is insufficient. The subpoena must be accompanied by a court order, or the consent of the member, unless specific exceptions exist (for example, an emergency as defined in the regulations).
• Documents are retained and stored securely in accordance with the Records Management Compliance Program – Government Markets Policy: GUID- 5089764.
• Any documents prepared for external review must be approved by the Manager, and in some cases the Law Department.
• A copy of the request is filed in the provider’s file.
• Obsolete records (electronic or hard copy) are destroyed or discarded in a controlled, consistent, and confidential manner in accordance with the Enterprise Risk and Governance Records Management Compliance Program policy.
• For data pertaining to alcohol/substance use, during an audit, if the audit or evaluation is conducted by a health oversight agency, (e.g., NYS Department of Health is on site for contract survey purposes), patient-identifying information may be disclosed so long as the health oversight agency makes the written commitments required by 42 CFR §2.53 and the disclosure meets the requirements in 45 CFR §164.512.
• Alcohol/Substance use: The records of patients treated for alcohol or drug use are protected from disclosure by both federal and state statutes. The federal restrictions on disclosure of such information are set forth at 42 U.S.C. §290dd-2 and in Regulations at 42 C.F.R. Part 2. These provisions generally prohibit the disclosure of records of the identity, diagnosis, prognosis, or treatment of any patient, which is maintained in connection with any alcohol or drug abuse program, conducted, regulated, or assisted by a federal department or agency, without the prior written consent of the patient or under very limited exceptions.
• If the health oversight agency copies or removes patient records, it must agree in writing to abide by the requirements of 42 CFR §2.53(b).
• Article 27-F of the Public Health Law prohibits the disclosure of information concerning whether an individual has been tested for or has contracted HIV/ AIDS and any information which identifies or reasonably could identify an individual as having one or more of such conditions. Section 33.13 of New York’s Mental Hygiene Law prohibits the disclosure of data relating to a person’s mental health. Any disclosure of information governed by these laws will be pre-approved by the Legal Department.

Provider Breach Notification Obligations

All personally identifiable information (“PII”) about Highmark’s Members (“protected health information” or “PHI”) is subject to state and federal statutory and regulatory privacy standards, including, without limitation, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), the Health Information Technology for Economic and Clinical Health Act (the “HITECH ACT”), and regulations adopted thereunder by the U.S. Department of Health and Human Services, 45 C.F.R. Parts 160, 162, 164 (“the HIPAA Rules”).

Provider must establish a program to effectuate full compliance with all applicable state and federal privacy and breach notification laws including, without limitation, HIPAA, 45 CFR §§ 164.400-414 (the “HIPAA Breach Notification Rule,”) and HITECH for the protection of PHI and PII, and for the notification of individuals, appropriate official bodies, and the media in the event of a breach of PHI or PII. Moreover, provider must maintain its privacy compliance and breach notification program in accordance with industry best practices.

Member Access to PHI

Members of Highmark products have a right to access (i.e., to review and/or obtain a copy of) their PHI that is contained in a designated record set. Generally, a “designated record set” contains medical and billing records as well as other records that are used to make decisions about our members’ health care benefits. Therefore, each practitioner must have a mechanism in place to provide this access.

Use of Measurement Data

Highmark uses measurement data to manage members’ health care needs through appropriate quality improvement programs such as health, wellness, and disease management programs.

Protection of Information Disclosed to Plan Sponsors or Employers

Highmark, in general, will disclose PHI only to an authorized representative of a self-insured group health plan. However, Highmark may provide summary health and enrollment information, which has been aggregated and de-identified, to fully insured group health plans and plan sponsors.

Robocalls

Highmark Inc. and its affiliated companies do not release information to artificial intelligence agencies. We will be glad to provide the information needed to the appropriate human stakeholders. Please have a human use our self-service tools available at highmark.com, through our provider portal, or call Customer Service for any information needed.

The Privacy Department

Highmark’s Privacy Department reviews and approves policies regarding the handling of PHI and other confidential information. Online privacy policy may be viewed at highmark.com. At the bottom of the page, click Privacy. 

1.4 Advising Members of Treatment Options

Highmark fully encourages and supports our network physicians’ efforts to provide advice and counsel and to freely communicate with patients on all medically necessary treatment options available, including medication treatment options, regardless of benefit coverage limitations, that may be appropriate for the member’s condition or disease.

In cases where the care, services, or supplies are needed from a provider who does not participate in Highmark’s networks, authorization must be requested.

Members must make decisions based on a full disclosure of options, including potential insurance coverage. Disclosure is the obligation of the treating provider.

Background

Some managed care plans may include a “gag clause” in their provider contracts that limits a network physician’s ability to provide full counsel and advice to enrollees.

Highmark network contracts for all products do not (and never did) contain such a “gag clause” relating to treatment advice, and, in Pennsylvania, complies with Act 68 requirements prohibiting such clauses.

Highmark fully encourages and supports our network physicians’ efforts to provide advice and counsel, and to freely communicate on all medically viable treatment options available, including medication treatment options, which may be appropriate for the member’s condition or disease regardless of benefit coverage limitations. Therefore, we do not penalize and have never penalized physicians for discussing medically appropriate care with the member.

1.4 Member Access to Physicians and Facilities

Accessibility Expectations for Providers

To stay healthy, members must be able to see their physicians when needed. To support this goal, we are sharing with you Highmark’s expectations for accessibility of primary care physicians (PCPs), medical specialists, behavioral health specialists, and obstetricians. The standards set forth specific time frames in which network providers should respond to member needs based on symptoms in an office and outpatient facility setting.

Physicians are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

Accessibility Expectations for Behavioral Health

To stay healthy, members seeking behavioral healthcare must be able to see their providers when needed. To support this goal, Highmark has specific expectations to ensure our members have access to behavioral health services in an office and outpatient facility setting. The standards set forth specific time frames in which a participating network provider should respond to a member needs based on symptoms.

Specifically, for members experiencing a crisis or non-life-threatening emergency, behavioral health offices must ensure immediate access to appropriate resources. This includes directing members to vital support options, such as the following:

• 988 Suicide and Crisis Lifeline
• Nearby behavioral health urgent care facilities
• Emergency department of a local hospital or psychiatric facility, or mobile crisis response teams

To facilitate seamless member navigation during critical moments, it is imperative that this vital information be integrated into the call scripts utilized by office receptionists, answering services, and customer service teams, thereby empowering every caller with immediate alternative options for urgent care.

Note: Standards for Highmark Healthy Kids (CHIP) enrollees are available in the Highmark Provider Manual's Chapter 2, Unit 3: Other Government Programs and may differ from the expectations noted below.

Acceptable After-Hours Methods

The chart below outlines acceptable methods of handling after-hours calls from your Highmark patients.

Availability of Facility Services

Facility services need to be available to Highmark members on a 24 hour per day, 7 day per week basis when medically appropriate and in accordance with industry standards.

Access to physician services is an integral component of the facility services provided to members. Physician services are provided by either hospital-based physicians or physicians employed by a facility. If physician services are provided to Highmark members on behalf of a facility, the facility must verify that physician has the appropriate training, education, and licensure to provide such services.

Equal Access and Non-Discrimination in Treatment of Members

In addition to requirements contained in your provider agreement and in any other applicable administrative requirements, network providers agree to requirements of equal access and non-discrimination of Highmark members within this manual.

Providers will provide members with equal access at all times to provider services. Providers agree not to discriminate in the treatment of Highmark members, or in the quality of services delivered, on the basis of place of race, national origin, ancestry, religion, sex, including sex stereotypes and gender identity, marital status, sexual preference, disability, age, or the Member’s source of payment, cost, anticipated cost, membership in a Product of Highmark or Health Plan or health status (to include, but not be limited to, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, conditions arising out of acts of domestic violence, or disability), or source of payment. Further, providers shall not deny, limit, discriminate or condition the furnishing of provider services to members based on their known or believed relationship or association with an individual or individuals of a particular race, color, national origin, sex, age, or disability.

1.4 Communication Aids and Services

Communications Access for Individuals with Hearing, Visual, or Speech Impairments

According to the U.S. Department of Justice’s Civil Rights Division (the “DOJ”), a “public accommodation” such as a physician’s office must provide auxiliary aids and services when necessary to ensure that the practice is communicating effectively with individuals with disabilities, unless providing such an aid or service would pose an undue hardship on the practice or fundamentally alter the services provided.

For example, according to the DOJ, if a person has a vision, hearing, or other sensory impairment and that impairment substantially limits the patient’s ability to communicate, a physician’s office must provide auxiliary aids or services to ensure equal access to medical care. The impairment can be one that the patient has from birth or one that has recently developed.

The type of auxiliary aid or service that must be provided will vary according to the length and complexity of the expected communication involved and the nature of the patient’s condition. Treating a hearing impaired patient for a simple cold or the flu may not require a physician’s office to hire a sign language interpreter. Exchanging written notes, typing back and forth on a computer, or using a family member to convey information may be effective.

On the other hand, discussing a complicated diagnosis or answering questions about a planned surgical procedure may require the use of a professional sign language interpreter. Similarly, practices may need to be prepared to have a telecommunication (TDD) device available to communicate effectively with deaf or speech impaired patients and may need to provide large print, audiotapes, or Braille materials for patients with significant sight impairments.

According to the DOJ, a practice may not charge a patient for the additional cost of providing such communication aids and services. Nor may it charge a patient directly for the cost of making the practice’s policies, practices, or procedures ADA-compliant. A health care provider is expected to treat the costs of providing auxiliary aids and services as part of the overhead costs of operating a business. 

1.4 Administrative Fee Collection Guidelines

Administrative Services That Are Permissible to Bill

Providers may collect fair and reasonable fees as permitted by law for providing the following administrative services:

• Completion of forms related to any of the following: employment, driver’s license, and school physicals.
• Providing copies of medical records for the member’s own personal use.

Note: The fees for completion of forms and the provision of copies are permissible when communicated to members in writing prior to requesting payment. In Pennsylvania, the limits on copying charges are updated annually based on the consumer price index and published in the Pennsylvania Bulletin.

Cancellation Fee Assessments

Highmark members are encouraged to keep scheduled appointments or to give adequate notice of delay or cancellation. This is communicated to commercial members in Delaware and to Medicare Advantage members in Pennsylvania as a member responsibility (see Chapter 1 Unit 5: Member Rights and Responsibilities).

Providers may collect a reasonable fee from Highmark members as permitted by law for missed appointments or for cancelling less than 24 hours before a scheduled appointment. If your office policy is to charge for missed appointments or untimely cancellations, this is acceptable as long as the policy is applicable to and enforced with all patients regardless of their payment method or insurance carrier. Members should be advised of the policy upfront prior to any services being rendered or fees assessed.

Providers Cannot Bill for These Services

Below please find common examples of when it is not appropriate to bill Highmark or its members for services. The information below is not an all-inclusive list.

1.4 After-Hours Physician Accessibility Study

The After-Hours Physician Accessibility Study is one of the methods by which physicians are evaluated to determine whether they meet accessibility standards.

Each practice meeting the following requirements participates in the after-hours study:

• New practice sites that have joined the network.
• An annual sample of existing practice site locations.
• Any practice site for which a member complaint (relating to after-hours access) has been received.
• Any provider who appeals a credentialing termination decision based on lack of 24/7 coverage. 

The table below describes the process for the after-hours accessibility study:

Practices that remain non-compliant following Step 3 of the process may be subject to additional corrective action, sanctioning, and, ultimately, network termination.

1.4 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, Highmark Care Benefits Inc., 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.

1.5 Introduction

1.5 Member Rights and Responsibilities - Delaware

1.5 Member Rights and Responsibilities - New York

1.5 Member Rights and Responsibilities - Pennsylvania

1.5 Member Rights and Responsibilities - West Virginia

1.5 Medicare Advantage Member Rights and Responsibilities - Delaware

1.5 Medicare Advantage Member Rights and Responsibilities - New York

1.5 Medicare Advantage Member Rights and Responsibilities - Pennsylvania

1.5 Medicare Advantage Member Rights and Responsibilities - West Virginia

1.5 Member Rights and Responsibilities - Highmark Healthy Kids (CHIP)

1.5 Disclaimers

1.5 Introduction

Highmark will treat members in a manner that respects their rights and will clearly communicate our expectations of member responsibilities to members, practitioners, and Highmark staff to promote effective health care, maintain a mutually respectful relationship with our members, and enhance cooperation among members, practitioners, and Highmark.

Highmark will communicate the member rights and responsibilities to all newly participating practitioners at the time of orientation via the Highmark Provider Manual and the applicable website, and annually to existing practitioners via the website. A paper copy will be provided upon request.

Highmark will communicate the member rights and responsibilities to the member through the member’s Health Care Certificate (may also be called a Health Care Benefit Booklet) upon enrollment, via the member website, and annually in the member newsletter.

1.5 Member Rights and Responsibilities - Delaware

The member rights and responsibilities for Highmark Blue Cross Blue Shield (DE) commercial products are outlined below.

Members have the right to: 

1. Be treated with courtesy, consideration, respect, and dignity.
2. Have their protected health information (PHI) and health records kept confidential and secure, in accordance with applicable laws and regulations.
   1. Receive communications about how Highmark Blue Cross Blue Shield (DE) (Highmark Delaware) uses and discloses their PHI.
   2. Request restrictions on certain uses and disclosures of their PHI.
   3. Receive confidential communications of PHI.
   4. Inspect, amend, and receive a copy of certain PHI.
   5. Receive an accounting of disclosures of PHI.
   6. File a complaint when they feel their privacy rights have been violated.
3. Available and accessible services when medically necessary, including urgent and emergent care 24 hours a day, 7 days a week.
4. Receive privacy during office visits and treatment.
5. Refuse care from specific practitioners.
6. Know the professional background of anyone giving them treatment. 
7. Discuss their health concerns with their health care professional.
8. Discuss the appropriateness or medical necessity of treatment options for their condition, regardless of cost or benefit coverage for those options.
9. Receive information about their care and charges for their care.
10. Receive from their provider, in easy to understand language, information about their diagnoses, treatment options including risks, expected results, and reasonable medical alternatives.
11. All rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medications and treatment after possible consequences of this decision have been explained to them in their primary language.
12. Received information about Highmark Delaware, its policies, procedures regarding its products, services, practitioners and providers, complaint procedures, and members’/enrollees’ rights and responsibilities.
13. Prompt notification of termination or changes in benefits, services, or the provider network.
14. Play an active part in decisions about their health care including formulating an advance directive.
15. Receive benefits and care without regard to race, color, gender, country of origin, or disability.
16. File a complaint with Highmark Delaware and receive a response to the complaint within a reasonable period of time.
    1. This includes requesting an internal appeal or review by an independent Utilization Review Organization, or filing a petition for arbitration for decisions made about their coverage.
    2. To register a complaint or request an appeal, members are instructed to call the Customer Service number listed on their ID card.
17. Submit a formal complaint about the quality of care given by their providers.
18. Make recommendations regarding Highmark Delaware’s members’ rights and responsibilities policies.

Members have the responsibility to:

1. Double-check that any facilities from which they receive care are covered by Highmark Delaware. They can visit myhighmark.com or call the Customer Service number listed on their ID card to ask about a facility.
2. Show their ID card to all caregivers before having care.
3. Keep their appointments. If they will be late or they need to cancel, give timely notice (in accordance with the provider’s office policy). They may be responsible for charges for missed appointments.
4. Treat their providers with respect.
5. Provide truthful information (to the extent possible) about their health to their providers. This includes notifying their providers about any medications they are currently taking.
6. Understand their health and participate in developing mutually agreed upon treatment goals.
7. Tell their health care providers if they do not understand the care he or she is providing.
8. Follow the advice of their health care provider for medicine, diet, exercise, and referrals.
9. Follow the plans and instructions for care that they have agreed on with their practitioners.
10. Pay all fees in a timely manner.
11. Maintain their Highmark Delaware eligibility. Notify Highmark Delaware of any change in their family size, address, or phone number.
12. Tell Highmark Delaware about any other insurance they may have.

1.5 Member Rights and Responsibilities - New York

Members have the right to:

1. Be treated with courtesy, consideration, respect, and dignity.
2. Receive information about Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY), its services, practitioners and providers, and members’/enrollees’ rights and responsibilities.
3. Voice complaints or appeals about the health plan or the care given by their providers.
4. Make recommendations regarding Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) members’ rights and responsibilities policies.
5. Confidentiality of their medical records.
6. Candid discussions concerning appropriate or medically necessary treatment options for their condition(s), regardless of cost or benefit coverage.
7. Request to see the physician selected for their primary care services instead of another member of his/her office staff for an office visit, if they are willing to wait for an available appointment.
8. Information about all services available through the health plan, including how to obtain emergency and after-hours care.

As a patient, members have a right to expect the following from their physicians or other providers:

1. Refuse treatment to the extent permitted by law, and to be informed of the medical consequences of that action.
2. Know the professional background of anyone giving them treatment; information can be obtained from the provider or the administrator of any health care facility.
3. Receive information from their physician or other provider necessary to give informed consent prior to the start of any procedure.
4. Receive from their provider, in easy to understand language, complete and current information about their diagnoses, treatment options including risks, expected results, and reasonable medical alternatives; when it is not advisable to give such information to a member, the information shall be made available to an appropriate person on their behalf.
5. Play an active part in decisions about their health care including formulating an advance directive.
6. Submit a formal complaint about the quality of care given by their providers; they can refer to their member handbook or contact customer service.

Members have the responsibility to:

1. Establish themselves as a patient of the physician they have selected for their primary care services.
2. Show their ID card to all caregivers before having care.
3. Follow carefully the health plan’s policies and procedures as described in their member handbook and their contract(s) and rider(s).
4. Provide truthful information (to the extent possible) about their health to their providers. This includes notifying their providers about any medications they are currently taking.
5. Understand their health and participate in developing mutually agreed upon treatment goals.
6. Be sure that their primary care physician coordinates any health care they receive in order to receive the highest level of benefits, if applicable under the terms of your plan coverage.
7. Keep their health plan informed of their concerns about the medical care they receive.
8. Follow the plans and instructions for care that they have agreed on with their practitioners.
9. Pay all fees in a timely manner, including appropriate copayments/deductible/coinsurance or other patient responsibility to providers when services or supplies are received.
10. Notify Highmark Blue Cross Blue Shield (WNY) or Highmark Blue Shield (NENY) (whichever is applicable) of any changes that affect them or their family, such as family size, address, or phone number.
11. Submit all bills they receive from a non-participating provider within one year from the date of service.
12. Tell Highmark Blue Cross Blue Shield (WNY) or Highmark Blue Shield (NENY) about any other group health insurance they may have or if anyone becomes eligible for Medicare.

1.5 Member Rights and Responsibilities - Pennsylvania

The member rights and responsibilities for Highmark commercial products in Pennsylvania are outlined below.

Members have the right to:

1. Receive information about Highmark, its products and its services, its practitioners and providers, and your rights and responsibilities.
2. Be treated with respect and recognition of your dignity and right to privacy.
3. Participate with practitioners in decision making regarding your health care. This includes the right to be informed of your diagnosis and treatment plan in terms that you understand and participate in decisions about your care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for your condition(s), regardless of cost or benefit coverage. Highmark does not restrict the information shared between practitioners and patients and has policies in place, directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or file an appeal about Highmark or the care provided, and receive a reply within a reasonable time period.
6. Make recommendations regarding the Highmark Members’ Rights and Responsibilities policies.

Members have the responsibility to:

1. Supply to the extent possible, information that the organization needs in order to make care available to you, and that its practitioners and providers need in order to care for you.
2. Follow the plans and instructions for care that you have agreed on with your practitioners.
3. Communicate openly with the physician you choose. Ask questions and make sure you understand the explanations and instructions you are given and participate in developing mutually agreed upon treatment goals. Develop a relationship with your doctor based on trust and cooperation.

1.5 Member Rights and Responsibilities - West Virginia

The member rights and responsibilities for Highmark Blue Cross Blue Shield (WV) commercial products are outlined below.

Members have the right to:

1. Receive information about Highmark Blue Cross Blue Shield (WV) (Highmark West Virginia), its products and services, its practitioners and providers, and member rights and responsibilities.
2. Be treated with respect and recognition of their dignity and right to privacy.
3. Participate with practitioners in decision making regarding their health care. This includes the right to be informed of their diagnosis and treatment plan in terms they understand and to participate in decisions about their care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for their condition(s), regardless of the cost or benefit coverage. Highmark West Virginia does not restrict the information shared between practitioners and patients and has policies in place directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or appeal about Highmark West Virginia or the care provided, and receive a reply within a reasonable period of time.
6. Make recommendations regarding the Highmark West Virginia Members’ Rights and Responsibilities policies.

Members have the responsibility to:

1. Supply to the extent possible, information that the organization needs in order to make care available to them, and that its practitioners and providers need in order to care for them.
2. Follow the plans and instructions for care that they have agreed on with their practitioners.
3. Communicate openly with the physician they choose. Ask questions and make sure they understand the explanations and instructions they are given, and participate in developing mutually agreed upon treatment goals.
4. Develop a relationship with their doctor based on trust and cooperation

Members receiving case management services from Highmark West Virginia are informed by letter at the initiation of services that they have the following rights:

1. Right to access needed health and social services.
2. Right to be informed of choices regarding services.
3. Right to be informed of available health care benefits, as well as where, when, and how they obtain these benefits.
4. Right to treatment with dignity and respect.
5. Right to have their health care records kept confidential except when disclosure is required by law or permitted in writing by them with adequate notice.
6. Right to be well-informed of any treatment plan in terms they understand, and to have input regarding decisions involving their medical care and treatment plan.
7. Right to comprehensive and fair assessment and notification of alternative approaches.
8. Right to receive notifications and rationale of discharge, termination, or change of service.
9. Right to withdraw from a case management program.
10. Right to an appeal/grievance procedure.
11. Right to choose a particular community service agency or long-term care provider.
12. Right to refuse treatment or services, including case management services, and be informed of the implications of such a refusal relating to benefits eligibility and/or health outcomes.
13. Right to obtain information regarding the plan’s criteria for case initiation and case closure.
14. Right to have informed consent for services, advance medical care directives (including end of life directives), and power of attorney documents to be followed in the case management process.
15. Right to have assistance in seeking additional resources for resolution of legal questions.
16. Right to have services/treatment rendered consistent with the Americans With Disabilities Act, worker’s compensation, and other laws protecting the rights of consumers as applicable.
17. Right to have alternative approaches to care if the member and/or family are not able to participate in the assessment process.

1.5 Medicare Advantage Member Rights and Responsibilities - Delaware

Members in Medicare Advantage Freedom Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, color, age, religion, national origin, or mental or physical disability.
2. To receive help with communication, such as help from a language interpreter.
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except when allowed or required by law.
5. Review and obtain copies of medical records, and to ask providers to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments.
9. Refuse treatment, including the right to leave a hospital or other medical facility against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment. 
10. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for himself/herself.
11. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
12. Get information about Highmark BCBSD Inc. (HBCBSD), which offers the Freedom Blue PPO product, health care coverage and costs, and network providers. Members may contact Member Services to request the following types of information:
    1. What services are covered and what the member has to pay;
    2. Explanation of any bills for services not covered;
    3. HBCBSD’s financial condition;
    4. Network providers and their qualifications;
    5. How Freedom Blue PPO pays physicians;
    6. Member rights and protections; and
    7. Summary of appeals and grievances Freedom Blue PPO has received.
13. Make recommendations regarding Highmark BCBSD Inc.’s, member rights and responsibilities policy.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
3. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
4. Pay plan premiums and any copayments the member owes for covered services they receive.
5. To contact Highmark Blue Cross Blue Shield (DE) Member Services with any questions, concerns, problems, or suggestions.
6. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible.

1.5 Medicare Advantage Member Rights and Responsibilities - New York

Members in Medicare Advantage Freedom Value HMO, Senior Blue HMO, BlueSaver HMO, Freedom Plus HMO, Freedom Blue PPO, Freedom Nation PPO, and Forever Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, age, religion, gender, health, ethnicity, creed (beliefs), sexual orientation, national origin, or mental or physical disability.
2. Receive information in a way that works for you and is consistent with your cultural sensitivities (in languages other than English, in large print or other alternate formats, etc.)
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except where allowed or required by law.
5. Review and obtain copies of medical records, know how they have been shared with others, and to ask Highmark to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time. You also have the right to get your prescriptions filled or refilled at any network pharmacies without long delays.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments. 
9. Refuse treatment- including the right to leave a hospital or other medical facility- against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for themself.
10. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
11. Members may contact Member Services to request the following types of information:
    1. Explanation of any bills for services not covered;
    2. The plan’s financial condition;
    3. Network providers and their qualifications;
    4. Pharmacies in our network and how we pay the providers in our network;
    5. Coverage information and rules to follow when using coverage
12. Make recommendations regarding Highmark
13. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Inform Highmark of any other health insurance coverage or prescription drug coverage.
3. Tell their doctor and other health care providers they are enrolled in our plan.
4. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
5. Be considerate and respect the rights of other patients. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
6. Pay plan premiums and any copayments the member owes for covered services they receive.

1.5 Medicare Advantage Member Rights and Responsibilities - Pennsylvania

The following information is made available to members through the Medicare Advantage Freedom Blue PPO, Community Blue Medicare PPO/PPO Plus, Community Blue Medicare HMO, and Security Blue HMO Member Evidence of Coverage booklets and updates in the member newsletters. The Member Evidence of Coverage booklets are available for viewing in the Highmark Provider Manual’s Appendix.

Medicare Advantage members have the right to:

1. Be assured they will not be discriminated against in the delivery of health care services consistent with the benefits covered in their plan based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
2. Receive considerate and courteous care, with respect for personal privacy and dignity.
3. Select their own personal physician/preferred provider or physician group from Highmark’s Medicare Advantage Primary Care Physician networks.
4. Expect their Primary Care Physician’s/network provider’s team of health care workers to provide or help them arrange for all the care that they need.
5. Participate in the health care process. If they are unable to fully participate in this discussion, they have the right to name a representative to act on their behalf.
6. Receive enough information to help them make a thoughtful decision before they receive any recommended treatment.
7. Be informed of their diagnosis and treatment plans in terms they understand and participate in decisions involving their medical care.
8. Talk openly with their Primary Care Physician and other network providers about appropriate and medically necessary treatment options for their condition, regardless of cost or benefit coverage.
9. Have reasonable access to appropriate medical services.
10. Be provided with complete information about their Medicare Advantage HMO/Medicare Advantage PPO, including the services it provides, the practitioners who provide care, and information on member rights and responsibilities.
11. Confidential health records, except when disclosure is required by law or permitted in writing by the member with adequate notice. Members have the right to review their medical records with their PCP or other network provider.
12. Express a complaint and to receive an answer to your complaint within a reasonable period of time.
13. Appeal a decision by Medicare Advantage if they feel they have been denied a covered service.
14. Immediate Quality Improvement Organization review of decisions for hospital discharges, as explained in the Centers for Medicare and Medicaid Services’ Important Message, which is given to Medicare members at the time of admission to a hospital, and in the Notice of Discharge and Appeal Rights given prior to discharge.
15. Call Member Services to request information about:
    1. How we control the use of medical services.
    2. The number of appeals and grievances we have received and how these cases were resolved.
    3. How we pay our participating doctors.
    4. The financial condition of our Plan.
16. Make suggestions about Medicare Advantage PPO and HMO policies on member rights and responsibilities.

Medicare Advantage members have the responsibility to:

1. Read all Medicare Advantage HMO and PPO materials carefully and immediately upon enrollment and ask questions when necessary. They have the responsibility to follow the rules of Medicare Advantage HMO/Medicare Advantage PPO membership.
2. Identify themselves as a Medicare Advantage HMO/Medicare Advantage PPO member when scheduling appointments, seeking consultations with their physician, and upon entering any Medicare Advantage HMO/Medicare Advantage PPO provider’s office.
3. Treat all Medicare Advantage HMO/Medicare Advantage PPO network physicians and personnel respectfully and courteously as your partners in good health care.
4. Communicate openly with the physician they choose. The member has the responsibility to develop a physician-patient relationship based on trust and cooperation.
5. Keep scheduled appointments or give adequate notice of delay or cancellation.
6. Ask questions and make certain that they understand the explanations and instructions they are given.
7. Consider the potential consequences if they refuse to comply with treatment plans or recommendations.
8. Pay any applicable copayments at the time of service.
9. Pay any applicable Medicare Advantage HMO/Medicare Advantage PPO premiums on time.
10. Pay their Medicare Part B premiums (and Part A, if applicable).
11. Help maintain their health and prevent illness and injury.
12. Help Medicare Advantage HMO/Medicare Advantage PPO maintain accurate and current medical records by being honest and complete when providing information to their health care professionals.
13. Express their opinions, concerns, or complaints in a constructive manner to the appropriate people at Medicare Advantage HMO/Medicare Advantage PPO.
14. Notify the Medicare Advantage HMO/Medicare Advantage PPO Member Service Department, Monday through Sunday, between 8 a.m. and 8 p.m. at 800-935-2583 (Medicare Advantage HMO) or 800-550-8722 (Medicare Advantage PPO) of any changes in their personal situation which may affect the Plan’s ability to communicate with them or provide health care to them, including any changes in their address or phone number, any extended trips or vacations, and of their return to the service area from a trip of up to six (6) consecutive months. TTY users, please call 711.
15. Understand their health problems and participate in developing mutually agreed-upon treatment goals to the degree possible.

1.5 Medicare Advantage Member Rights and Responsibilities - West Virginia

Members in Medicare Advantage Freedom Blue PPO plans are informed through their Member Evidence of Coverage booklets that they have certain rights and responsibilities. The Freedom Blue PPO Member Evidence of Coverage booklet is available for viewing in the Highmark Provider Manual’s Appendix.

Medicare Advantage members have the right to:

1. Not be discriminated against because of race, color, age, religion, national origin, or mental or physical disability.
2. To receive help with communication, such as help from a language interpreter.
3. Be treated with dignity, respect, and fairness at all times.
4. Privacy of medical records and personal health information. Generally, health information will not be released to anyone who is not providing or paying for the member’s care without written permission from the member, except when allowed or required by law.
5. Review and obtain copies of medical records, and to ask providers to make additions or corrections to the records.
6. Obtain care from network and non-network providers. To choose a network provider (and be informed which physicians are accepting new patients). To see a women’s health specialist (such as a gynecologist) without a referral or prior authorization
7. Timely access to providers and to see specialists when care from a specialist is needed. “Timely access” means to get appointments and services within a reasonable amount of time.
8. Get full information from providers when obtaining medical care and to participate fully in decisions about their care. Providers must explain things in a way the member can understand. The member’s rights include knowing about all the treatment choices that are recommended for the member’s condition, regardless of cost or coverage. This includes the right to be told about any risks involved. Members must be told in advance if any proposed treatment is part of a research experiment and be given the choice of refusing experimental treatments.
9. Refuse treatment, including the right to leave a hospital or other medical facility against a physician’s advice, and to stop taking medication. The member accepts responsibility for the consequences of refusing treatment.
10. Ask someone, such as a family member or friend, to help make health care decisions. This includes executing advance directives, such as a living will or power of attorney for health care, or to authorize someone to make decisions in the event the member becomes unable to make decisions for himself/herself.
11. Make a complaint or appeal if the member has concerns or problems related to coverage or care.
12. Get information about Highmark Senior Solutions Company (“HSSC”), which offers the Freedom Blue product, health care coverage and costs, and network providers. Members may contact Member Services to request the following types of information:
    1. What services are covered and what the member has to pay;
    2. Explanation of any bills for services not covered;
    3. HSSC’s financial condition;
    4. Network providers and their qualifications;
    5. How Freedom Blue pays physicians;
    6. Member rights and protections; and
    7. Summary of appeals and grievances Freedom Blue has received.
13. Make recommendations regarding Highmark Senior Solutions Company’s member rights and responsibilities policy.

Medicare Advantage members have the responsibility to:

1. Become familiar with their coverage, the rules they must follow to obtain care, and what they have to pay.
2. Give their physician and other health care providers the information they need to provide care. To follow the treatment plans and instructions that they and their physicians agree upon. To ask questions of their physician or other provider if they have them.
3. Act in a way that supports the care given to other patients and helps the smooth operation of the physician’s office, hospital, or other office.
4. Pay plan premiums and any copayments the member owes for covered services they receive.
5. To contact Highmark West Virginia Member Services with any questions, concerns, problems, or suggestions.
6. Understand their health problems and participate in developing mutually agreed upon goals, to the degree possible. 

1.5 Member Rights and Responsibilities - Highmark Healthy Kids (CHIP)

Highmark makes health care programs available to uninsured children in Pennsylvania through the subsidized Children’s Health Insurance Program of Pennsylvania (CHIP) called Highmark Healthy Kids (CHIP). Highmark is committed to providing CHIP enrollees with the highest quality care possible and is dedicated to serving them in a manner that respects their rights as individuals and maintains confidentiality about personal medical matters.

Until July 1, 2022, the following provider networks serviced children covered under CHIP: the Premier Blue Shield preferred provider network in the 21-county Central Region; the Keystone Health Plan West (KHPW) managed care network in the 29- county Western Region; and the First Priority Health (FPH) managed care network in the 13-county Northeastern Region. The children and parents have the right to timely and effective redress of complaints, grievances, and appeals about Highmark or the care provided by participating network providers.

Since July 1, 2022, Highmark has had an HMO CHIP network that services 62 counties of Pennsylvania.

Highmark encourages CHIP members and their parents to know and exercise their rights and responsibilities as outlined below. Network participating providers who provide care to CHIP enrollees are expected to know and respect these rights and encourage member responsibilities.

Highmark Healthy Kids (CHIP) members/parents have the following rights:

1. Receive information about Highmark, its products and services, its practitioners and providers, and members’ rights and responsibilities.
2. Be treated with respect and recognition of their dignity and right to privacy.
3. Participate with practitioners in decision-making regarding their health care. This includes the right to be informed of their diagnosis and treatment plan in terms that they understand and participate in decisions about their care.
4. Have a candid discussion of appropriate and/or medically necessary treatment options for their condition(s), regardless of cost or benefit coverage. Highmark does not restrict the information shared between practitioners and patients and has policies in place, directing practitioners to openly communicate information with their patients regarding all treatment options regardless of benefit coverage.
5. Voice a complaint or appeal about Highmark or the care provided, and receive a reply within a reasonable period of time.
6. To be free from any form of restraint or seclusions used as a means of coercion, discipline, convenience, or retaliation. 
7. To be free to exercise their rights and exercising these rights will not adversely affect the way Highmark treats them.
8. Make recommendations regarding the Highmark Members’ Rights and Responsibilities policies.
9. The right to change Managed Care Organizations or disenroll.
10. Protection from overcharges or liability for costs.
11. The right to all covered services on the first day of enrollment.
12. Be furnished with covered health care services.
13. Have privacy protected as stipulated by 42 CFR 457.1110. This includes compliance with federal and state laws relating to the confidentiality and safeguarding of information.
14. Highmark shall provide a copy of a member’s records or information timely upon request. Highmark shall permit the member to request that the information or records be supplemented or corrected.
15. Highmark shall comply with applicable federal and state laws relating to member rights and must require that its employees and Providers observe and protect member rights.

Highmark Healthy Kids (CHIP) members/parents have the following responsibilities:

1. Supply to the extent possible, information that the organization needs to make care available to them, and that its practitioners and providers need to care for them.
2. Follow the plans and instructions for care that they have agreed on with their practitioners.
3. Communicate openly with the physician they choose, ask questions and make sure they understand the explanations and instructions they are given, and participate in developing mutually agreed upon treatment goals. Develop a relationship with their doctor based on trust and cooperation.
4. Make timely premium payments.
5. Cooperate with the enrollment/renewal process.

1.5 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, Highmark Care Benefits Inc., 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.