4.1 Primary Care/Specialist Essentials

4.1 Treatment of Immediate Relatives

4.1 PCP and Medical Specialist Accessibility Expectations

4.1 Primary Care Practitioner Overview

4.1 Primary Care Practitioner Role and Responsibilities

4.1 How Members Select and Change PCPs

4.1 Arranging For PCP Absence

4.1 Member Removal Policy and Procedure

4.1 How to Close and Re-Open Your Practice to Members

4.1 First Priority Health Network PCP Payment Methodology (PA Only)

4.1 PCP and Specialist Communication

4.1 Specialist Basics

4.1 Preventive Care Responsibilities For All Network Physicians

4.1 OB/GYN Requirements and Procedures

4.1 Obstetrical Services

4.1 Gynecological Services

4.1 Breast Pumps and Lactation Counseling

4.1 Disclaimers

4.1 Primary Care/Specialist Essentials

While primary care physicians/practitioners (PCPs) play an important role in managing all aspects of health care for members who select their practice, specialists in Highmark’s networks play an equally important role of providing specialty services to Highmark members.

Primary Care/Specialist Communication

Highmark network primary care physicians, primary care CRNPs, and specialists, including medical, surgical, and behavioral health, must communicate with one another to assure continuity and coordination of care for members. Where the networks support managed care products, Highmark will monitor compliance of the communication procedure as part of the medical record review program.

For additional information, please see the PCP and Specialist Communication section in this unit.

New Member

The Medical Director, the Director of Utilization Management, or a nurse reviewer may issue an administrative referral for continuity of care or as medically necessary under the following conditions:

• A new member requires specialty care, but the PCPs office cannot accommodate a new member visit immediately.
• A new member changes PCPs and current referrals are terminated, but continued specialty care is required.
• Continuation of active care occurs under the following circumstances:
  • If the provider's participation terminates, the member may continue to receive care for up to 90 days. The 90 day transitional period begins on the date the provider's contractual obligation with the health plan to provider services terminates.
  • If the member is in the second or third trimester of pregnancy, she may continue receiving care from a terminated provider through delivery and the postpartum period.
  • New members in the second or third trimester of pregnancy may continue to see out-of-network providers for delivery and postpartum care.
  • New members who are disabled or have degenerative and/or life-threatening conditions or diseases, may continue to see out-of-network providers for up to 60 days from the date of enrollment.

Involving Members In Health Care Decisions

Highmark and providers must continually work together to encourage and support members taking an active role in their health care by:

• Providing consideration for member input when developing treatment plans;
• Informing members of appropriate follow-up care;
• Arranging or providing training in self-care and other measures that impact health status; and
• Addressing barriers to member compliance with prescribed treatments or regimens.

Advising Members of Treatment Options Policy

Highmark fully encourages and supports our network physicians’ efforts to provide advice and counsel and to freely communicate with patients on all medically necessary viable treatment options available, including medication treatment options, regardless of benefit coverage limitations, that 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 patient.

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

Highmark does not prohibit or otherwise restrict a health care professional, acting within the lawful scope of practice, from advising, or advocating on behalf of, an individual who is a patient and enrolled under a Highmark plan, about:

• The patient’s health status, medical care, or treatment options (including any alternative methods of treatments that may be self-administered), including the provision of sufficient information to the individual to provide an opportunity to decide among all relevant treatment options;
• The risks, benefits, and consequences of treatment or non-treatment; or
• The opportunity for the individual to refuse treatment and to express preferences about future treatment decisions.

Reminder: In cases where the care, services, or supplies are needed from a provider who does not participate with Highmark, authorization must be requested.

Voluntary or Involuntary Specialist Termination from the Networks

In the event of the voluntary or involuntary termination of a Highmark provider agreement, the specialist/specialty group must cooperate with Highmark in its efforts to obtain information regarding those members enrolled in managed care products that may be affected by such termination because they are undergoing an ongoing course of treatment or are otherwise active patients of the specialist/specialty group. Such information includes the name, address, and identification number of the affected managed care members.

This information must be provided timely so that affected members may be notified prior to the effective date of the termination. Highmark has a process in place to notify these members as obligated by state regulation and federal law.

Highmark’s Communication Policy

From time to time, Highmark will announce changes to administrative or reimbursement policies. In cases where such changes have a direct impact on the provider, it is Highmark’s policy to give providers adequate notice regarding these changes. Informational changes will be announced in no less than thirty (30) days in advance, unless the change decreases reimbursement in an adverse way in which there will be written notice ninety (90) days in advance, or it changes our credentialing/recredentialing policies in which case written notice will be given sixty (60) days in advance, unless required by law or regulation.

4.1 Treatment of Immediate Relatives

Charges imposed by immediate relatives of the patient or members of the patient’s household:

General

These are expenses that constitute charges by immediate relatives of the patient or by members of their household. The intent of this exclusion is to bar Highmark reimbursement for items and services that would ordinarily be furnished gratuitously because of the relationship of the patient to the person imposing the charge.

This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the corporation that employs the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.

Payment may be made for charges imposed on immediate relatives or household members by a professional provider to recover expenses incurred in furnishing covered items or supplies, such as drugs and biologicals, prosthetic devices, etc.

Immediate Relative

The following degrees of relationship are included within the definition of immediate relative:

• Spouses
• Natural or adoptive parent, child, and sibling
• Stepparent, stepchild, stepbrother, and stepsister
• Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law
• Grandparent and grandchild; and
• Spouse of grandparent and grandchild

Members of Patient's Household

These are persons sharing a common abode with the patient as a part of a single-family unit, including those related by blood, marriage or adoption, domestic employees, and others who live together as part of a single-family unit. A mere roomer or boarder is not included.

Charges for Provider Services

Payment will not be made by Highmark for items and services furnished by providers to immediate relatives of the owner(s) of the corporation that employs the providers. This exclusion applies whether the provider is a sole proprietor who has an excluded relationship to the patient, or a partnership in which even one of the partners is related to the patient.

Charges for Physician and Physician-Related Services

This exclusion applies to physician services, including services of a physician who belongs to a professional corporation, and services furnished incident to those services (for example, by supervised services incident to their services has an excluded relationship to the beneficiary).

Professional corporation means a corporation that is completely owned by one or more physicians and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by state law. Any physician or group of physicians which is incorporated constitutes a professional corporation. (Physicians who are incorporated identify themselves by adding letters such as P.C. or P.A. after their title.)

Charges for Items Furnished by Nonphysician Suppliers

This exclusion applies to charges imposed by a nonphysician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related. It does not apply to charges imposed by a corporation (other than a professional corporation), regardless of the patient’s relationship to any of the stockholders, officers, or directors of the corporation or to the person who furnished the service.

4.1 PCP and Medical Specialist Accessibility Expectations

Accessibility Expectations for Providers

To stay healthy, members must be able to see their physicians when needed. To support this goal, Highmark’s expectations for accessibility of primary care physicians (PCPs), medical specialists, and obstetricians are outlined below. 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.

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.

Note: Standards for Highmark Healthy Kids/Pennsylvania Children’s Health Insurance Program (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.

4.1 Primary Care Practitioner Overview

Highmark managed care members may select a primary care physician or practitioner (PCP) in accordance with their managed care program requirements. PCPs play an important role in managing all aspects of health care for members who select their practice.

Definition of PCP

A PCP is the medical professional who provides a patient’s care and helps them access a range of services. The PCP provides, coordinates, and/or authorizes the health care services covered by the managed care program.

Practitioners Who May Serve as PCPS

A physician (MD or DO) who is a family practitioner, general practitioner, internal medicine practitioner, or pediatrician is entitled to participate as a PCP. The physician must complete the credentialing process.

In addition, certified registered nurse practitioners (CRNPs) may offer their clinical expertise as a primary care CRNP to Highmark members. Qualified CRNPs must complete a credentialing application and meet credentialing requirements to receive designation as a primary care CRNP with Highmark. CRNPs who receive primary care CRNP designation with Highmark can only participate in Highmark’s provider networks in that capacity; they cannot serve as both a CRNP specialist and a primary care provider.

How PCPS are Reimbursed

PCPs in most Highmark networks are paid fee-for-service; however, PCPs participating in the First Priority Health (FPH) managed care network in Pennsylvania’s Northeastern Region receive capitation, unless otherwise set forth in your participating provider agreement.

Please see the section in this unit on First Priority Health Network PCP Payment Methodology for more information on FPH network payment methodology.

PCP Selection Requirements

Highmark members enrolled in the following products are required to select a PCP to manage their care:

Pennsylvania:

• Commercial HMO plans in the Western and Northeastern Regions
• Medicare Advantage HMO plans -- Security Blue HMO, offered only in the Western Region, and Community Blue Medicare HMO
• Highmark Healthy Kids (CHIP) HMO plan

Delaware:

• Independent Practice Association (IPA) and Point of Service (POS) products require the selection of a PCP. 

West Virginia:

• Members in Super Blue Select POS plans are required to select a PCP at the time of enrollment.

Traditional indemnity products and PPOs do not require PCP selection. In Pennsylvania, EPO products do not require PCP selection but it is recommended.

4.1 Primary Care Practitioner Role and Responsibilities

Highmark managed care members may select a primary care physician/practitioner (PCP) in accordance with their managed care program requirements. The PCP provides, coordinates, and/or authorizes the health care services covered by the managed care program.

PCPs play an important role in managing all aspects of health care for members who select their practice. The information to follow serves as an introduction to the roles and responsibilities of the PCP.

Managed care members are required to select a PCP from our directory of participating providers. The PCP is responsible for monitoring his/her patients and coordinating the delivery of all health care services, including preventive and routine medical care, hospitalization, and specialized care within the network. If an enrollee is using a behavioral health clinic that also provides primary care services, the enrollee may select lead provider to be PCP.

PCP Responsibilities

Responsibilities specific to primary care physicians and primary care CRNPs, if within the scope of their license, include, but are not limited to:

• Office visits
• Inpatient hospital, emergency room, skilled nursing, and home visits
• Routine pediatric and adult immunizations
• Maintenance allergy injections
• Routine diagnostic procedures
• Minor surgeries performed in office (as applicable)
• Lab services performed in the office
• Preventive and early detection interventions
• Most acute and chronic services
• Other services as necessary
• Maintaining organized medical record keeping practices and ensuring accurate medical records
• Maintaining active staff privileges at a minimum of one Highmark contracted hospital*
  
  • Risk Adjustment Data Verification (RADV)
• Providing 24-hour telephone availability year round
• Providing 24/7 physician coverage
• Obtaining authorization for services as required
• Informing Medicare Advantage members about advance directives (applicable in Pennsylvania and West Virginia)
• Cooperating with Highmark quality management programs to the extent permitted by federal and state law including, but not limited to, the following:
  • Clinical initiatives
  • Condition management and shared decision making
  • Credentialing
  • Clinical studies
  • Health Plan Employer Data and Information Set (HEDIS®)
• Providing access to members’ medical records

Note: Routine adult and pediatric physicals and pediatric immunizations must be performed by the member’s PCP, if applicable, to receive coverage.

*Primary care CRNPs must have full admitting privileges or a plan of action with a network participating primary care physician with admitting privileges, with consideration to the age range of patients (e.g., a general practitioner who sees patients age 13 years and older should not cover hospital admissions for a CRNP with a pediatric practice who sees patients under 13 years of age).

Primary Care Physician

A primary care physician's role is that of a medical manager, providing and coordinating medical care for Highmark members. A primary care physician is responsible for determining the health care needs of his/her patients, for directly providing many of these needs and for coordinating the services of other providers. Primary care specialties include family practice, general practice, internal medicine, geriatrics, adolescent medicine, and pediatrics.

To remain in compliance with New York State laws, primary care physicians must make arrangements with other participating providers to ensure that Highmark members have access to health care 24 hours per day, seven days per week. An "on-call provider" covers for another. The name of the on-call provider should be indicated on the provider application form at the time of credentialing and re-credentialing. Providers should follow the guidelines below when selecting providers to cover their practices:

1. Individual provider practices are limited to five on-call providers.
2. All providers of the same specialty within a group can be on call for each other.
3. Specialists cannot be on call for PCPs.
4. Specialists can only be on call for specialists in the same field.
5. All on-call providers must be participating providers with Highmark.

It is the responsibility of the provider to notify the File Data Management Department of any changes to who is covering for his/her practice. If a provider is covering on a temporary basis only, Provider File Data Management should be notified of the specific dates that he/she will be covering. The following criteria explain that family practice physicians must have a coverage agreement for each major component of their active practice with a physician that has an active practice in the same component (adult medicine, pediatrics, and OB-GYN). It may be necessary for the family practice physician to have more than one practitioner for coverage agreement(s) for their active practice(s) as described in the table below. Pediatric practice physicians must have coverage agreement(s) with physicians that have an active pediatric component within practice(s).

Adult medicine physicians must have coverage agreement(s) with physicians that have an active adult medicine component within their practices.

Organizational Provider Communication

Highmark network organizational providers, such as hospitals, emergency facilities, ambulatory surgery centers, home health agencies, and skilled nursing facilities, must promote continuity and coordination of care for network members by communicating with primary care physicians and primary care CRNPs when care is delivered to their patients.

Primary care physicians and primary care CRNPs should expect a written description of the care given to their patients any time services have been rendered by these providers.

4.1 How Members Select and Change PCPS

How Members Select a PCP

Managed care members with coverage requiring a PCP selection are asked to select a PCP at the time of enrollment.

• Pennsylvania: Members with coverage under commercial health maintenance organization (HMO) plans in the Western Region, Medicare Advantage HMO plans in the Western Region, and Highmark Healthy Kids (CHIP) HMO plan.
• Delaware: Members with Independent Practice Association (IPA) and Point of Service (POS) plans are required to select a PCP.
• West Virginia: Members in Super Blue Select POS plans must select a PCP and are informed that benefits will be paid at the lower, self-referred level if they do not select a PCP.

Managed care members who are required to select a PCP may select any network PCP listed in the provider directory they receive at enrollment as long as the following conditions are met:

• The PCP practice is open to new members.
• The member fits into the PCP’s patient age range as specified by specialty, e.g., pediatrics.

Members in PPO/EPO and traditional indemnity plans, including Medicare Advantage Freedom Blue PPO plans in Pennsylvania and West Virginia, are not required to formally select a PCP. These members may select or switch PCPs as they choose without notifying Highmark.

How Members Change PCPS

Highmark members may call into Member Service and select a new PCP at any point after enrollment.

Transfer of Medical Records

When a member chooses a new PCP, the original PCP must transfer the member’s complete medical record to the new PCP in a timely manner (at no charge to the member).

4.1 Arranging for PCP Absence

The purpose of this section is to explain what the PCP needs to do before leaving for vacation or other time off.

Making the Necessary Arrangements

Prior to leaving for an extended period of time off, the PCP should:

1. Find a PCP who participates in the same network(s) as you to provide medical treatment to members during your absence.
2. Resolve payment arrangements, including copayments.
3. Inform office staff of the above arrangements and ask that the covering physician inform his/her office staff of the arrangements.
4. Be sure that your answering service informs patients of the arrangement.

PCP Back-Up Physician Form

PCPs in Highmark West Virginia’s Point of Service (POS) network select a back-up physician at the time of contracting with Highmark West Virginia by completing the Primary Care Physician Back-Up Physician Information Form.

The PCP may change his/her designated covering physician by submitting a new form. However, use of a non-network physician for coverage must be authorized by Highmark West Virginia. Please contact Highmark Provider Information Management at 800-798-7768

Appointments

Most members will be able to wait for their regular PCP’s return. However, there will be some cases when a member will require an office visit during his/her PCP’s absence. For such cases, the covering PCP’s office staff should make an appointment or arrangements and give the member clear directions.

Authorization Requests During the PCP’S Absence

If the PCP is planning to be away for a short duration (less than five days), the covering PCP can request authorizations and advise members to go to specialists or the emergency room during the PCP’s absence.

The covering physician may keep a list of these incidents which he/she then shares when the member’s PCP returns. For the treatment that took place during the absence, the member’s PCP should submit any authorization requests expediently to avoid payment delays.

Reimbursement and Copayments

We advise physicians to work out their own payment arrangements prior to covering for one another. We do not provide additional reimbursement to practitioners who are covering for other PCPs.

The collection of copayments works the same way. The two physicians involved should come to an agreement as to how this will be handled.

Informing the Office Staff

It is imperative that both the regular and the covering physicians’ office staff be aware of any temporary coverage arrangements. Failing to notify the office staff may decrease continuity of care to members.

4.1 Member Removal Policy and Procedure

Policy

All Highmark members have a responsibility to maintain a cooperative physician/patient relationship. Documented occurrences of members not fulfilling their responsibilities may result in a practitioner requesting discharge of the member from his/her practice.

Background

The relationship between a PCP and his/her members is crucial in the managed care environment. However, sometimes problems can occur which cause a serious rift in the doctor/patient relationship. In such cases, we ask the PCP to attempt to resolve the matter directly with the member. If this does not correct the problem, the PCP is supported in his/her effort to remove the member from the practice.

Invalid Reasons for Removing a Member

Invalid reasons for removing a member include:

• Race.
• Sexual orientation.
• Age (unless the member’s age is outside of the scope of the practice, e.g., an adult patient in a pediatric practice).
• National origin.
• Diagnosis.
• Physical disability.
• Religion.
• Gender.
• Health status factors (e.g., medical condition, claims experience, receipt of health care medical history, genetic information, or evidence of insurability).
• Health care insurance coverage.
  

Before You Request Removal…

Removing a member from your practice should be used as a last resort. You must make a sincere attempt to resolve the situation with the member prior to requesting his/her removal. Your efforts must be documented in the member’s chart.

Procedure for Removing a Member from Your Practice

If a problem is identified, the practitioner must communicate the problem to the member or the member’s legal representative and document the problem in the member’s medical record.

When a PCP has exhausted his/her best efforts to establish an effective relationship and has documented situation(s), the PCP may apply to Highmark to have the member transferred from the PCP’s practice. Written requests for physician/patient relationship termination should be submitted to: 

Note: It is not necessary to send a written request for members with coverage that does not require a PCP selection.

The request must contain the following information:

• Member name.
• Member ID number and insurance product.
• Member address.
• Member telephone number.

Also included with each request should be statements which document:

• Specific documentation of the nature and timing of the incident(s) which gave rise to the request as evidenced in the medical record.
• The steps which the PCP has taken to resolve the situation and/or to establish an acceptable relationship with the member.
• Other relevant information pertinent to the request for terminating the physician/patient relationship.

A practitioner or designee from the practice must sign the request. A copy of the request should also be sent to the member.

The PCP must provide access to service until the termination date and provide urgent care if necessary. If requested to do so by the member or Highmark, the practitioner must, at no cost to the patient, forward medical records to the new PCP within 30 days.

4.1 How to Close and Re-Open Your Practice to Members

This section is intended to explain how to close and re-open your practice to new members.

Definition: Closed Practice

When a practice is “closed to new members,” it means that the PCP practice is temporarily not available for selection by new members.

Definition: New Member

A new member is one who has:

• Never been seen by a physician of the practice.
• Not been seen by a physician of the practice within the past 36 months.

Rationale

By closing to new members, your practice can limit the number of new members. This can be especially helpful to practices that are new to managed care, or to practices that have a shortage of physicians or office staff.

Guidelines

• Your practice must provide written notice to Highmark 60 days prior to the anticipated closing date and/or re-opening date.
• Closure takes place on the first day of the month following the 60-day period.
• You must continue to accept new members up to the end of the 60-day period when closure is in place. You must accept existing members who choose you as their PCP.
• You must close to all new Highmark plan members.

How to Close or Re-Open Your Practice

To close or to re-open your practice to new members, simply mail or fax written notification on practice letterhead, including practice name, address, vendor number, effective date, and authorized signature for the requested change, to: 

• Fax: 800-236-8641
• Mail: Highmark Blue Shield
  • Provider Information Management
    P.O. Box 898842
    Camp Hill, PA 17089-8842

4.1 First Priority Health Network PCP Payment Methodology (PA Only)

The First Priority Health (FPH) managed care provider network supports the health maintenance organization (HMO) products in the 13-county Northeastern Region of Pennsylvania. Highmark also uses FPH for the Highmark Healthy Kids (CHIP) program. There are several reimbursement methodologies available to primary care physicians (PCPs) participating in the FPH network. These include capitation, billables, copayments, and fee-for-service reimbursement as more specifically set forth in your FPH participating provider agreement.

FPH PCP Capitation

Capitation is a prepaid dollar amount, determined actuarially, which is paid to the PCP for each patient who has chosen his/her office. It is calculated to average a fee-for-service equivalent. The dollar amount is based on a predetermined rate per age group, regardless of any one patient’s use of services. The dollar amount varies based on copayment, age category, and provision of venipuncture.

Capitation checks are issued on the first of the month and the dollars paid are for services provided during that month. Capitation services are not prorated. The date on which additions or deletions to your office are effective determines whether your office will receive or repay a full month’s payment.

Changes effective from the first through the fifteenth of the month are calculated for capitation purposes for the entire current month. Changes which are effective from the sixteenth through the end of the month are effective on the first day of the following month.

If you do not have a copy of the capitation rates, please contact Provider Services.

Some examples of services covered under capitation include, but are not limited to:

• Office visits and outpatient services rendered at the PCP’s office.
• Drawing of blood and other laboratory specimens (if the office is located in a laboratory program region, these specimens should be sent to the assigned laboratory provider – please see the Highmark Provider Manual Chapter 4 Unit 5: Outpatient Radiology and Laboratory for more information).
• Physical examinations, including routine, camp, college, scouts, driver’s license, or school physicals, are covered under capitation once every 12 months. If the member has had a physical examination within less than twelve (12) months and requests another exam for non-medical reasons, it is not a covered service because it is not considered medically necessary and, therefore, the member is responsible for payment.
• EKGs (electrocardiograms).
• Services not listed on the billable list are considered covered under capitation. 

Foreign service physical exams, pre-employment physicals, or exams required by insurance companies are not covered; the member is responsible for payment of these services.

Important: It is critical that ALL services rendered to members are submitted for payment or adjudication as pre-paid. This includes capitated (prepaid) services in addition to the PCP billable procedures, which are paid fee-for-service. Highmark requires this billing/encounter information to monitor clinical activities, comply with accrediting bodies, and provide PCPs with fair capitation payments and accurate reports. All payments for non-medically necessary services and/or non-covered benefits are the member’s responsibility.

Capitation Roster

The capitation roster is a monthly financial statement intended for use by the provider’s business office. In the roster’s heading, totaled capitation information for the provider practice is provided, including total number of members, total capitation rate for all members, the total amount of adjustments (if applicable), and the total capitation payment for the month for all members.

The capitation roster also lists, alphabetically, all members enrolled with your practice. Due to the time required to process new members or PCP selection changes, sometimes there is a delay of one to two months before a new member may appear on the roster. The following information is included on the roster for each member:

• Member Name/Member ID.
• Date of Birth/Age.
• Sex.
• Effective Date with PCP.
• Copay Amount.
• Capitation Rate.
• Adjustment Amount/Date, if applicable.
• Capitation Payment.

The capitation roster is available at the beginning of every month via Availity. It is accessed by going to Payer Spaces and then clicking Quality Blue and navigating to Quality Blue reports.

• The roster is generated by “provider group,” not by “physicians within the group.”
• The roster can be downloaded to a PDF or text file.
• A history of rosters will be available at all times within Quality Blue.
• Providers receiving Highmark capitation via electronic funds transfer (EFT) will only receive the roster via Quality Blue.
• Providers receiving a paper check will receive the roster by mail in addition to the ability to access the roster via Quality Blue.
  

FPH PCP Billables

Billables are certain services the PCP may submit for fee-for-service reimbursement consideration in addition to his/her capitation payments. The PCP must submit claims with all the required information via an 837P electronic claim transaction or a paper claim using an original 1500 Health Insurance Claim Form, Version 02/12 (photocopies, discontinued, or outdated versions will not be accepted).

Please refer to the PCP Billable Services list for procedures that are billable for fee-for-service reimbursement. 

FPH PCP Copayments

For any office visit where a member seeks “professional medical attention,” the patient is responsible for a copayment at the time services are rendered. Copayments should be collected only for office visits billed with an evaluation and management code. Highmark follows the current year evaluation and management codes as published in the American Medical Association CPT Manual.

Please refer to the member’s current ID card or Availity’s Eligibility and Benefits Inquiry for the correct copayment amount to be collected. A member’s copayment cannot exceed the allowed amount (contracted rate). If the allowed amount is less than the member’s designated copayment, providers should only collect up to the allowed amount.

Please check your remittance advice for the appropriate member liability (copayment, deductible, and/or coinsurance). If you collected the copayment at the time services were rendered and the remittance advice indicates a lower copayment, the member must be reimbursed the difference.

4.1 PCP and Specialist Communication

Network personal physicians and specialists, including medical, surgical, and behavioral health, must communicate with one another to assure continuity and coordination of care for members. The communication procedure is documented below.

The goal is to ensure the exchange of information in an effective, timely, and confidential manner to promote appropriate diagnosis and treatment for members.

Requirements

PCPs and specialists, including medical, surgical, and behavioral health specialists, must communicate in each of the following ways to ensure continuity of patient care:

• Before the member’s visit to the specialist, the PCP must provide relevant clinical information to the specialist. Acceptable forms of communication are formal letters and/or copies of relevant portions of the patient’s medical chart. The Patient Treatment Summary Communication Form is available on the Provider Resource Centers in Pennsylvania and West Virginia – select Forms, and then Miscellaneous Forms.
• Within 10 business days of the first visit, the specialist must provide the PCP with information about his/her visit with the member. Acceptable methods of communication are standardized form, formal letter, and/or copies of relevant portions of the patient’s medical record.
• In the case of behavioral health, the member’s consent may be needed for the behavioral health specialist to release information to the PCP. If a patient refuses to give consent, the behavioral health specialist must document this refusal in the patient’s behavioral health treatment record.
• The PCP must document his/her review of the reports, lab, X-rays, and other diagnostic tests received from the specialist or facility in the patient’s chart. The PCP must also indicate any subsequent action necessary. The PCP should indicate that he/she has reviewed the information (e.g., by initialing each page).

Member Role in Communication

Highmark members should not be asked by PCPs or specialists to communicate findings, reports, lab results, etc. to another practitioner.

PCP/Behavioral Health Form

Behavioral health providers in Pennsylvania may use the Communication Document for Behavioral Health Specialist to Primary Care Physician to communicate with the member’s PCP. This form can also be found on the Provider Resource Centers in Pennsylvania – select Forms, and then Behavioral Health Forms.

Copying and Transferring Medical Records

Providers must ensure members are guaranteed timely access to their medical records, X-rays, and other information that pertains to them. The following requirements apply to the transfer and copying of medical records for Highmark members:

• PCPs must transfer sufficient medical records (or copies thereof) and information to Specialists without charge to the member or Highmark, as is necessary for the Specialist to appropriately treat the member.
• Specialists must provide PCPs, without charge to the member or Highmark, written documentation regarding medical care given or being given to the member. (Additional restrictions may apply to information regarding certain medical conditions such as mental health, substance abuse, and HIV/AIDS).
• PCPs must transfer, without charge to the member or Highmark, sufficient medical records and information to another if the member requests to change his/her PCP.
• In general, practitioners must transfer to each other appropriate medical information as necessary to ensure quality care for all members. The transfer of medical records must be completed in a timely fashion and without charge to the member or Highmark to ensure continuity of care.
• When releasing records directly to the patient, at the patient’s request, the practitioner may charge a reasonable fee to cover copying and postage costs, up to the amount set by state law and as permitted by federal law.

Compliance Monitoring

Where the network supports managed care products, Highmark will monitor compliance of the communication procedure as part of the medical record review process. During medical record review, Highmark representatives will check for the provider’s initials on the member’s chart and ensure that any necessary follow-up actions are addressed.

The goal is to ensure the exchange of information in an effective, timely, and confidential manner to promote appropriate diagnosis and treatment for members.

Organizational Provider Communication

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

4.1 Specialist Basics

As a specialist, you play the important role of providing specialty services to our Highmark members.

In New York, the specialty care physician is responsible for responding to the referral from the primary care physician.

How Specialists are Reimbursed

Network specialists are paid fee-for-service. For more information on reimbursement methods, see the Highmark Provider Manual Chapter 6 Unit 7: Payment/EOBs/Remittances.

How Auxiliary Personnel are Reimbursed

When physicians employ auxiliary personnel (e.g., non-physician such as a certified registered nurse) to assist in rendering services to their Highmark members and include the charges for those services in their own bills, the services of such personnel are considered to be “incident to” the physician’s services. Services of auxiliary personnel are covered when there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct personal supervision by the physician.

More detailed information about supervision guidelines of ancillary personnel and employment guidelines can be found in Medical Policy Bulletin Z-27: Eligible Providers and Supervision Guidelines.

Highmark’s Medical Policies are available on the Provider Resource Center under Policies and Programs.

If Network Participation is Terminated

In the event of voluntary or involuntary termination the specialist or specialty group from any of Highmark’s networks, upon request, are required to cooperate with network policies in obtaining a list of members that may be affected by such termination because they are undergoing an ongoing course of treatment or are otherwise active plan members. The list must include name, address, and identification number.

Highmark will use the member list to initiate its member notification process to alert them that the specialist or group will no longer be a part of the network. 

Directing Care to Network Providers

As a provider who participates in a managed care network, it is your obligation to provide services at the most appropriate level and to protect Highmark members from business practices which expose them to unnecessary out-of-pocket expenses. This means, among other things, that when your Highmark members require services that you are not able to provide, you are obligated to direct those members to other providers who participate in the network associated with their benefit program.

For more information on directing care to network providers, please see the Highmark Provider Manual Chapter 3 Unit 1: Network Participation Overview.

4.1 Preventive Care Responsibilities for All Network Physicians

Network physicians have a unique opportunity to recommend or administer certain services and lifestyle improvements that can prevent future illness or injury. Benefits are provided for prevention, early detection, and minimization of ill effects and causes of disease.

Highmark charges its PCPs and specialists with promoting and helping to maintain the health of members through the HEDIS^® measures and other preventive services as noted below.

PCP and Specialist Responsibilities

• Adhere to nationally accepted preventive health guidelines as approved by Highmark.
• Provide or recommend beta-blocker treatment after heart attack and promoting long-term therapy.
• Recommend and promote timely and age-appropriate preventive services, e.g., screening for breast, cervical, colorectal, and prostate cancers.
• Recommend a follow-up behavioral health visit within seven days and no later than 30 days after hospitalization for mental illness and ensuring compliance with medication and long-term follow-up.
• Evaluate members to determine tobacco use. Advise and assist members to cease tobacco use.
• Recommend the Baby Blueprints® program to members who could benefit from participating in this program.
• Provide or recommend adequate care for diabetics, including foot and eye exams.
• Use recommended depression screening tools to identify depression in members and initiate appropriate, ongoing treatment.
• Recommend members to condition management programs when appropriate and available under their benefit plan.
• Provide appropriate and comprehensive care for members with hypertension.
• Prescribe appropriate medications for members based on current national standards of care.
• Promote exercise and physical activity to all members, especially the senior population.

Note: Routine adult and pediatric physicals and pediatric immunizations must be performed by the member’s PCP, if applicable, to receive coverage.

Clinical Practice and Preventive Health Guidelines

On an annual basis, Highmark’s Quality Management, along with participating network physicians, review and update the Clinical Practice and Preventive Health Guidelines.

These guidelines are available online to the provider community as a reference tool to encourage and assist you in planning your patients’ care. The guidelines can be found under Resources and Education on the Provider Resource Center.

Additional Information Related to OB/GYN Care

• Provide or recommend screening mammograms, cervical cancer screenings, and Chlamydia screenings.
• Recommend Baby Blueprints® to expectant Highmark members so that they may better understand and enjoy every stage of pregnancy and make more informed care and lifestyle decisions.
• Provide or recommend prenatal care, especially in the first trimester.
• Provide or recommend post-partum exams 4-6 weeks after delivery.
• Provide appropriate counseling for menopause.
• Evaluate the risk of child abuse, domestic violence, and elder abuse.
• Evaluate the risk of post-partum depression.

Documentation

Network physicians should submit accurate encounters/claims and document their preventive care services and recommendations in the member’s chart.

If performed by a specialist, the intervention, including dates they were performed and their results, should be communicated in writing to the PCP.

Likewise, information about such interventions performed by the PCP should be communicated to a specialist when the information is pertinent to the condition the specialist is treating.

4.1 OB/GYN Requirements and Procedures

Obstetricians and gynecologists (OB/GYNs) in Highmark’s networks play a very important role by providing health care to our female members. Women have direct access to any network OB/GYN for their health care needs.

Direct Access

Direct access to women’s health care means that no members in need of gynecological or obstetrical services need to obtain referrals from their primary care physicians/practitioners (PCPs).

Direct access offers the following advantages for members seeing a credentialed network OB/GYN:

• No referral for annual routine gynecological exam.
• No referral for sick visits.
• No referral for follow-up care.
• No referral for maternity services.

Direct access does not extend to services provided by OB/GYN residents or to gynecological services provided in a hospital clinic setting.

Members have access to two annual routine gynecological exams.

Communication Procedure

Direct access enables members to have contact with their OB/GYNs without going through their PCPs. While this enhances member satisfaction, communication between OB/GYNs and PCPs is still vital, especially when routine annual gynecological exams and mammograms are provided.

The following should be faxed or mailed within 30 days to the member’s PCP for each office visit:

• Clinical findings.
• Test results.
• Treatment plans.
• A summary report at the conclusion of the treatment period.

Acceptable formats include typed letters, physician forms, and progress notes.

OB/GYN Referrals

If an OB/GYN sees a member and determines that the member may need the services of another specialty practitioner, the OB/GYN should recommend that the member return to their PCP. OB/GYNs are not authorized to refer members to other specialty practitioners.

If a member requests a visit for symptoms that do not appear to be gynecological in nature, the OB/GYN should refer the member back to her PCP.

4.1 Obstetrical Services

Highmark members have direct access to women’s health care and are not required to obtain referrals from their primary care physicians/practitioners (PCPs) for maternity care.

Verifying Benefits

Highmark recommends that you always verify benefits prior to providing service to our members because member benefits can vary. Ensure you do so for each of these special circumstances:

• Dependent daughter’s eligibility for maternity benefits.
• Coverage for tubal ligation.
• Hospital employees and their dependents – some may have coverage or high-level coverage only at their employer hospitals.

To verify benefits, please use the Eligibility and Benefits feature in Availity^®. If you do not have access to Availity, please call Provider Services for your service area to speak to a customer service representative.

Note: Maternity authorizations are not necessary unless the care is provided out-of-network.

Case Management Available

Case management is a systematic, proactive, and collaborative approach to effective assessment, monitoring, and evaluation of options and services required to meet an individual member’s health needs. Case management is a collaborative process involving the physician, the patient and support system, the case manager, and other health care service providers to encourage and assist patients to achieve their optimum level of wellness, self-management, and functional capability.

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.

Baby Blueprints^® Program Available!

Baby Blueprints® is a free program that offers expectant Highmark members educational information on all aspects of pregnancy through multiple printed and online resources during each trimester of pregnancy. Topics include prenatal care, proper use of medications, avoiding alcohol and tobacco, working, travel considerations, nutrition and weight gain, exercise, body changes, and many others.

For more information on this program, please visit the Highmark Provider Manual Chapter 2 Unit 4: Benefit Plan Programs.

Spontaneous Abortion

In the case of a spontaneous abortion, the obstetrician should retrospectively bill for all prenatal visits.

Directing Members for Appropriate Care

If a member requests a visit for symptoms that do not appear to be obstetrical or gynecological in nature, please direct the member to contact her PCP.

OB/GYN Network Participation

For Highmark network participation requirements and procedures, please see the Highmark Provider Manual Chapter 3 Unit 3: Professional Provider Guidelines.

4.1 Gynecological Services

Highmark members have direct access to women’s health care and are not required to obtain referrals from their primary care physicians/practitioners (PCPs) for gynecological services. Direct access offers the following advantages for members seeing a credentialed network OB/GYN:

• No referral for annual routine gynecological exam.
• No referral for sick visits.
• No referral for follow-up care.

Annual Routine Gynecological Exams

Annual routine gynecological exams include, but are not limited to, the following services:

• Pelvic exam.
• Pap test.
• Clinical breast exam.
• Interval history.

Follow-Up Visits

Follow-up visits may include the following services:

• Screening mammography.
• Diagnostic mammography.
• Selected diagnostic and surgical procedures, only if not on the list of procedures requiring pre-authorization.
• Lab services referred by the OB/GYN.
• Additional office visits, if necessary.

Mammography

A prescription is required to order a mammogram.

Mammography Screening vs. Diagnostic Mammography

A screening mammogram is an ordinary check-up intended to detect any problems. A diagnostic mammogram is a test intended to follow-up on a confirmed or suspected irregularity or diagnosis.

Infertility Services Require a Benefit

Not all members have a benefit to cover testing and/or treatment for infertility and/or assisted fertilization. To verify coverage, please use the Eligibility and Benefits feature in Availity. For inquiries that cannot be handled via Availity, please call the Provider Service Center for your service area.

Directing Members for Appropriate Care

If a member requests a visit for symptoms that do not appear to be gynecological in nature, please direct the member to contact her PCP.

OB/GYN Network Participation

For Highmark network participation requirements and procedures, please see the Highmark Provider Manual Chapter 3 Unit 3: Professional Provider Guidelines.

4.1 Breast Pumps and Lactation Counseling

Under the Affordable Care Act of 2010 (ACA), specific women's preventive health care services are required to be covered for eligible health plan members without cost sharing to members. Such services include breastfeeding support, supplies, and lactation counseling services.

Coverage at a Glance

Breastfeeding support, counseling, and supplies are covered ACA Women’s Preventive Health Services Mandate with no cost sharing to the member when performed by in-network providers.

• Out-of-network coverage is pursuant to the terms of the member's individual benefits.
• Out-of-network cost sharing and balance billing may apply.
• Only durable medical equipment (DME) providers can bill for breast pumps and supplies.

Verify Eligibility and Benefits

You can verify whether a Highmark member is covered under the federal Women’s Preventive Health Mandate via Availity Essentials® or the applicable HIPAA electronic transactions.

Breastfeeding Pumps and Supplies

Breastfeeding pumps and supplies are covered without cost sharing for women covered under the ACA Women’s Preventive Health Services Mandate. Eligible members are entitled to one breast pump per pregnancy when supplied by any network participating durable medical equipment supplier.

Eligible Highmark members can order high-quality breast pumps directly from two of the leading manufacturers in the industry: Ameda and Medela. Members can call the selected manufacturer or place an order online in advance of their delivery. The manufacturer will confirm a member’s eligibility and submit claims to Highmark for processing. Eligible members can be directed to contact the manufacturers as follows:

Breastfeeding Supplies Procedure Codes

For eligible members whose coverage falls under the ACA women’s health mandate, breast pumps and supplies are covered without member cost sharing when provided by participating DME providers. The following are eligible procedure codes for breastfeeding pumps and supplies:

Lactation Counseling/ Support

Based on the ACA mandate, lactation services are eligible with no member cost sharing as follows:

• When provided by credentialed physicians who can employ lactation consultants or use their nursing staff to provide support. (This includes services provided by a physician assistant [PA] or certified registered nurse practitioner [CRNP] when under the supervision of a credentialed physician. Lactation consultants are not credentialed and cannot receive direct payment for their services.)
• When billed using the appropriate procedure codes — 99401, 99402, and 99403 — and the appropriate diagnosis code of Z39.1.

Additionally, breastfeeding counseling/support is eligible with no age limit or frequency restrictions, and lactation counseling/support is considered to be a preventive service.

Please also note the following:

• When the service is provided by the pediatrician, then it is integral to the baby exam.
• When a lactation consultant provides the service in the pediatrician office, the billing is for the mother.
• When the services are provided as part of the maternity hospitalization, the payment is bundled and paid per the facility contract and integral to that admission.
• The service is part of the standard preventive schedule for non-grandfathered groups (NGF); please check Availity Essentials® for benefit coverage.

For More Information

Highmark Medical Policy E-37 includes medical guidelines not outlined in the ACA mandate; however, these medical policy guidelines would apply to those groups that do not follow the Women’s Health Federal Mandate. The policy addresses:

• Newborns who are detained in the hospital after the mother is discharged.
• Babies who have congenital anomalies that interfere with feeding.

Highmark Medical Policy can be accessed from the Provider Resource Center by selecting Policies and Programs from the main menu.

4.1 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.

4.2 General Information

4.2 Levels of Care

4.2 Opioid Treatment Program Benefit

4.2 Delaware Senate Bills 41 and 109 – Drug and Alcohol Dependency Treatment

4.2 Highmark Behavioral Health Programs

4.2 Accessibility Expectations for Behavioral Health

4.2 Treatment Information and Patient Privacy

4.2 Behavioral Health Provider and PCP Communication

4.2 Documentation Standards for Outpatient Services

4.2 Inpatient Consultations for Patients on Medical Units

4.2 Follow-up Appointments After Hospitalization

4.2 Disclaimers

4.2 General Information

Verify Benefits

Behavioral health benefits vary by product and by group. In some instances, a group may purchase medical health care coverage through Highmark, but behavioral health care coverage through another company.

To determine whether a member has behavioral health care coverage through Highmark and if authorization is required, always verify the member’s benefits prior to providing services. Eligibility and benefits can be verified via Availity Essentials^® or the applicable HIPAA electronic transaction. If you do not have electronic access, call Highmark Behavioral Health Services or the benefits telephone number on the member’s identification card.

Eligibility and Benefits Inquiry 

To verify behavioral health benefits via Availity, click Patient Registration and then select Eligibility and Benefits Inquiry from the task bar.

Contact Information

To reach Highmark’s Behavioral Health Services, call:

• Delaware (DE), New York (NY), Pennsylvania (PA), and West Virginia (WV): 800-258-9808
  • Fax for DE and PA: 877-650-6112
• New York (NY) Behavioral Health Utilization Management: 844-946-6264
  • Fax: Behavioral Health UM Outpatient: 833-581-1867 or Behavioral Health UM Inpatient: 833-581-1866

DE, PA, and WV – standard business hours for the Behavioral Health Services department are:

• Monday through Friday from 8:30 a.m. to 7 p.m.
• Saturday from 8:30 a.m. to 4:30 p.m. (limited staffing for urgent requests)

NY – standard business hours for the Behavioral Health Services departments are:

• Monday through Friday 8:15 a.m. to 5 p.m.
• After these hours, there is a prompt if you want to speak to a nurse. When you press the prompt, the call is forwarded to the On Call Service (Answer Phone).

Medical Management Services

Highmark Behavioral Health Services provides behavioral health medical management services for members enrolled in Highmark programs.

Utilization Management

For most Highmark products, authorization is required to receive coverage for all inpatient behavioral health services. Although authorization is not required for emergency services, an authorization is required if an emergency service results in an inpatient admission.

Some outpatient services also require prior authorization. These include the following:

• Applied Behavioral Analysis (ABA) for Autism
• Intensive Outpatient Programming (IOP)
• Partial Hospitalization Programming (PHP)
• Transcranial Magnetic Stimulation (TMS)

Highmark Behavioral Health Services provides timely utilization management determinations for all members and providers based on established medical necessity criteria. Each utilization management determination is handled in a manner consistent with the clinical urgency of the situation and with legal and regulatory compliance requirements.

For more information, see the Highmark Provider Manual's Chapter 5, Unit 4: Behavioral Health.

Virtual Behavioral Health

Highmark participating behavioral health providers have the option of providing “virtual” behavioral health visits for Highmark members via telecommunications technology. The services performed must fall under the scope of the provider’s license, and the sessions must be conducted following Highmark’s recommended service and security guidelines.

For more information, see the Highmark Provider Manual's Chapter 2, Unit 5: Telemedicine Services.

Referrals to In-Network Providers

When recommending inpatient services, be sure that the member is to receive care from a provider that participates in the network associated with the member’s program and, when applicable, is in the highest benefit tier.

4.2 Levels of Care

Least Restrictive Setting

Highmark Behavioral Health Services operates from the foundational principle that optimal, high-quality care occurs when the member receives the services that meet his or her needs in the least intensive, least restrictive setting safely available within the scope of his or her benefit plan.

Levels of Care

Highmark Behavioral Health Services has defined the following levels of care for mental health and substance abuse treatment services:

• Inpatient Hospitalization:
  • Psychiatric
  • Withdrawal Management (ASAM Level 4)
• Residential Treatment:
  • Psychiatric
  • Substance Use Disorder (ASAM Level 3.5 or 3.7)
  • Withdrawal Management
• Outpatient Treatment:
  • Medication Management
  • Outpatient Therapy
• Intensive Outpatient, including:
  • Psychiatric
  • Substance Use Disorder
• Partial Hospitalization Program, including:
  • Psychiatric
  • Substance Use Disorder

Coverage and Requirements May Vary by Product and Benefit Plans

Behavioral health benefits may vary by product and may also vary by the specific contract under which the member has coverage. All levels of care may not be covered by the member's benefit plan. In addition, pre-certification and concurrent review requirements apply and may vary by benefit type.

Always verify a member's plan-specific benefits via Availity Essentials or by calling Highmark Behavioral Health Services prior to providing services.

Inpatient Hospitalization

Inpatient hospitalization is the highest level of skilled psychiatric and substance-abuse treatment services. It is provided in facilities such as freestanding psychiatric hospitals or distinct-part psychiatric or detoxification units of an acute care hospital.

Settings eligible for this level of care are licensed at the hospital level and provide 24-hour medical and nursing care.

Residential Treatment Centers

The residential treatment center level of care is defined as a non-hospital setting that provides twenty-four (24) hour residential care to persons with long-term or severe mental disorders and persons with substance-related disorders. These programs feature the following:

• Treatment with a range of diagnostic and therapeutic behavioral health services that cannot be provided through existing community programs
• Training in the basic skills of living, as determined necessary for each patient

Licensure requirements for this level of care vary by state.

Partial Hospitalization Programs (PHPs)

Partial hospitalization programs (PHPs) are defined as structured and medically supervised outpatient day or evening treatment programs. Although the patient is not considered a resident, the services provided are of essentially the same nature and intensity as those provided in an inpatient setting.

Highmark treats partial hospitalization as a professional service and, if eligible, is considered part of a member’s outpatient mental health or substance abuse treatment benefit.

Partial hospitalization services are designed to address a mental health or substance abuse disorder through an individualized treatment plan provided by a coordinated multidisciplinary team. Highmark defines partial hospitalization programs as providing, at a minimum, the following treatment: 

• Psychosocial assessment within the first program day
• Substance abuse evaluation within the first two program days
• Clinical assessment once daily
• Individual/group/family therapy at least four hours per day, three or more days per week
• Psychiatric/medication evaluation once per week
• Toxicology screen/self-help or education groups as needed

Note: School-based programs must also adhere to the hourly requirements regardless of the number of days a member is treated per week (e.g., three hours per day; five days per week does not meet criteria).

Intensive Outpatient Programs (IOPs)

Intensive outpatient programs (IOPs) provide planned and structured services to address mental health and/or substance-related disorders.

Highmark defines intensive outpatient programs as providing, at a minimum, the following treatment:

• Psychosocial assessment within the first visit
• Substance abuse evaluation within the first two visits
• Individual/group/family therapy at least 2.5 hours per day, two or more days per week
• Psychiatric/medication evaluation as needed
• Toxicology screen/self-help, 12-step, or education groups as needed

The coordinated and integrated multidisciplinary services provided by an intensive outpatient program may include the services listed below:

• Group, individual, family, or multi-family group psychotherapy
• Multiple or extended treatment/rehabilitation/counseling visits
• Professional supervision and support
• Crisis intervention, psychiatric/psychosocial rehabilitation, or day treatment models
• Psycho-educational services
• Adjunctive services such as medical monitoring

Note: These services are provided by an intensive outpatient program-contracted facility or agency.

Important: Self-Help Programs

While treatment for substance abuse typically involves participation in self-help programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), these programs are offered without charge by community volunteers and cannot be included as billable time in an intensive outpatient program.

Medical Director Required for PHPs and IOPs

All facilities providing partial hospitalization and/or intensive outpatient programs and submitting claims via 1500 must have a Medical Director.

The Medical Director must be a medical doctor (MD) or doctor of osteopathic medicine (DO) with a board certification in psychiatry in good standing who is credentialed and participating with Highmark.

Facilities contracting for substance abuse only can alternatively have a medical doctor (MD) or doctor of osteopathic medicine (DO) who is also certified in addiction medicine by a Member Board of American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA), or American Society of Addiction Medicine (ASAM).

Traditional Outpatient Treatment

Traditional outpatient treatment is typically individual, family, and/or group psychotherapy and consultative services, including nursing home consultation and psychiatric home health visits.

Service duration ranges from 15 minutes (e.g., medication checks) to 50 minutes (e.g., individual or family psychotherapy) and can extend as long as two hours (e.g., group psychotherapy). 

Supervised Living Is Not a Covered Service

Supervised living services, which provide assistance but not medically necessary care, are not covered under Highmark benefit plans.

4.2 Opioid Treatment Program Benefit

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 is aimed at addressing the nation’s opioid overdose epidemic.

As required by the SUPPORT Act, the Centers for Medicare and Medicaid Services (CMS) will pay Medicare-enrolled Opioid Treatment Programs (OTPs) through bundled payments for Opioid Use Disorder (OUD) treatment services provided to Medicare beneficiaries in an episode of care. OTPs must enroll in the Medicare program to receive reimbursement when these services are provided to Medicare patients.

Medicare Advantage plans are also required to include the OTP benefit and can contract with Medicare-enrolled OTP providers in their service area.

Opioid Treatment Programs Defined

Opioid Treatment Programs provide medication-assisted treatment for people diagnosed with OUD. The programs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by an independent, SAMHSA-approved accrediting body.

For SAMHSA certification, OTPs must comply with all pertinent state laws and regulations and all regulations enforced by the Drug Enforcement Administration.

Services Covered Under the OTP Benefit

As defined by CMS, the following services used for the treatment of OUD are covered under the OTP benefit:

• Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications
• The dispensing and administering of MAT medications (if applicable)
• Substance use counseling
• Individual and group therapy
• Toxicology testing, which includes both presumptive and definitive testing
• Intake activities
• Periodic assessments 

OTP Services HCPCS Codes

Highmark’s OTP benefit for our Medicare Advantage plans is similar to the CMS OTP benefit that pays for bundled services under Medicare Part B for Medicare beneficiaries. A bundled payment for the overall management, care coordination, individual and group psychotherapy, and substance use counseling for OUD creates an avenue for clinicians to bill for a group of services in the office setting.

Codes that have been created describe a weekly bundle (HCPCS codes G2067-G2075), with one week defined as seven (7) contiguous days. Additional codes for add-on services (HCPCS codes G2076-G2080) for evaluation/assessment, take-home supplies of medication, or for billing counseling/therapy services that substantially exceed the amount specified in the member’s individualized treatment plan. The member’s medical records must be documented to show the medical necessity for these add-on services.

These codes are specifically used by OTPs for OUD treatment services. These codes can only be billed by Medicare-enrolled OTP providers.

Per Medicare guidelines, the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as telehealth services using communication technology as clinically appropriate.

Provider Enrollment

To provide OUD treatment services to Highmark Medicare Advantage members under the OTP benefit, OTP providers must meet the same requirements as those providing services under Medicare Part B (including enrollment with Medicare). Medicare-enrolled OTPs can submit an application to contract with Highmark to provide these services to Highmark Medicare Advantage members.

Refer to the MLN Opioid Treatment Programs (OTPs) Medicare Enrollment Fact Sheet for more information about the Medicare enrollment requirements and process.

Claim Submission

Opioid Treatment Program providers must submit all claims for OUD treatment services covered under the OTP benefit via an 837P electronic transaction or the 1500 Health Insurance Claim Form. Include the following information:

• HCPCS codes associated with the OTP service provided to the member
• OTP’s NPI in the Rendering Provider Identifier section in Box 24J of the 1500 form or its equivalent on the electronic 837P
• Prescribing or other eligible professional provider’s NPI in Box17 (the ordering/referring/other field) of the 1500 form or the equivalent field on the electronic 837P

For More Information

For additional information, see the Opioid Treatment Programs page on the CMS website.

4.2 Delaware Senate Bills 41 and 109 – Drug and Alcohol Dependency Treatment

Delaware Senate Bill 41 was written in an effort to reduce overdose deaths related to the growing opioid epidemic. The bill was enacted into law on May 30, 2017, amending Title 18 of the Delaware Code relating to coverage for serious mental illness and drug and alcohol dependency (Del. Code tit. 18 §§ 3343, 3578).

The law requires coverage for medically necessary inpatient and residential drug and alcohol dependency treatment and immediate access to a 5-day emergency supply of prescription medications. It also prohibits insurers from imposing precertification, prior authorization, pre-admission screening, and referral requirements for the diagnosis and medically necessary treatment, including inpatient, of drug and alcohol dependencies, and does not allow concurrent utilization review for the first 14 days of inpatient and residential treatment.

Delaware Senate Bill 109, signed into law on Sept. 29, 2017, also amends Title 18 and further extends the restriction on concurrent utilization review to include 30 days of intensive outpatient treatment and five days of inpatient withdrawal management.

Applicability

These statutes are applicable to all Highmark Delaware fully insured individual and group health benefit plans. Self-insured employer groups will be offered the opportunity to adopt the mandate and may or may not elect to follow the mandate. Medicare supplemental plans are exempt from this law.

Definition

Drug and alcohol dependencies are defined as a substance abuse disorder or the chronic, habitual, regular, or recurrent use of alcohol, inhalants, or controlled substances as identified in Chapter 47 of Title 16 of the Delaware Code.

Inpatient and Residential Treatment Requirements

Under this legislation, health plan coverage for drug and alcohol dependencies must include:

• Inpatient coverage; and
• Unlimited medically necessary treatment provided in residential settings as required by the federal Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).

Prescription Drug Coverage for a 5-Day Emergency Supply

If a health plan’s coverage includes prescription drugs, the plan must provide immediate access, without prior authorization, to a five-day emergency supply of prescription medications for treatment of serious mental illness and drug and alcohol dependencies, including a prescribed drug for opioid withdrawal, stabilization, or overdose reversal, except where otherwise prohibited by law.

The five-day emergency supply may be subject to copayments, coinsurance, and annual deductibles if consistent with those imposed on other benefits within the health benefit plan. However, a plan may not impose an additional copayment or coinsurance on a covered person who receives a subsequent 30-day supply of the same medication in the same 30-day period in which the person received the emergency supply.

Benefit Management Restrictions

As per the legislation, Highmark Delaware may not impose precertification, prior authorization, pre-admission screening, or referral requirements for the diagnosis and medically necessary treatment, including inpatient, of drug and alcohol dependencies at a Highmark Delaware network participating facility.

In addition, concurrent utilization review is prohibited during the first 14 days of medically necessary inpatient and residential treatment by a network participating facility approved by a nationally recognized health care accrediting organization or the Division of Substance Abuse and Mental Health; 30 days of Intensive Outpatient Program treatment; or five days of inpatient withdrawal management.

However, the facility must comply as follows:

• The facility must notify Highmark Delaware of both the admission and the initial treatment plan within 48 hours of the admission.
• The facility must perform daily clinical review and periodically consult with Highmark Delaware to ensure that the facility is using the evidence-based and peer-reviewed clinical review tool used by Highmark Delaware and designated by ASAM or, if applicable, any state-specific ASAM criteria and appropriate to the age of the patient to ensure that the inpatient treatment is medically necessary for the patient. 

Retrospective Review

Highmark Delaware may perform retrospective review for medical necessity and appropriateness of all services provided during an inpatient stay or residential treatment, including the initial 14 days of treatment; 30 days of Intensive Outpatient Program treatment; or five days of inpatient withdrawal management.

Highmark Delaware may deny coverage for any portion of the initial 14-day inpatient or residential treatment on the basis that the treatment was not medically necessary only if the treatment was contrary to the evidence-based and peer-reviewed clinical review tool used by Highmark Delaware and designated by ASAM or any state-specific ASAM criteria.

The Highmark Delaware member does not have any financial obligation to the facility for inpatient and residential treatment other than any applicable copayments, coinsurance, or deductible amounts required under their benefit plan.

Reminder: Verify Benefits

You can verify benefits, including whether the member’s benefit plan follows the mandate, via Availity’s Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.

If Availity is not available, call the Highmark Provider Service Center.

4.2 Highmark Behavioral Health Programs

The need for more access to behavioral health resources is a growing trend among health care consumers. To meet the needs of our members, Highmark is taking a hands-on approach to enhancing various behavioral health programs available to our members. Professionally trained staff are available to members, their families, significant others, and providers to coordinate the services needed to meet our members’ needs.

Case and Condition Management Programs

Highmark offers health coaching through behavioral health case management and chronic condition management approaches. The objective of the programs is to facilitate the member’s self-management plans for lifestyle improvement and activities relative to their specific circumstances or diagnosis, address potential barriers to goal achievement, and assist in referrals to providers, community, and/or other resources and support.

For example, the condition management services specific to depression help members identify symptoms of depression; overcome the reluctance that many people have to getting help; decide if formal treatment is indicated and, if so, what the right treatment may be; locate services; manage barriers; and assist in tracking progress.

Role of the Behavioral Health Specialist

The behavioral health specialist plans, implements, coordinates, monitors, and evaluates the preferences and services to meet the member’s behavioral health care needs. The behavioral health specialist assesses the member throughout the case management or condition management process, working with the member to identify short and long-term goals that address the member’s specific needs.

Highmark’s behavioral health specialists are licensed behavioral health professionals who receive formal training in motivational interviewing and other behavior change approaches. This training enables behavioral health specialists to communicate effectively with members via telephone and other approved technologies to establish and monitor both short and long-term goals for improved health management.

Utilization Management Team's Role

The utilization management team assists in applying medical necessity criteria to avoid variation in the delivery of services, recommends clinically appropriate alternative levels of care, and assists in discharge planning. Highmark behavioral health utilization management has become an integral part of ensuring timely and appropriate discharge planning and triaging referrals to other programs in Highmark. The care managers on the team promote continuity of care.

Recommending a Member to a Behavioral Health Program

Providers are encouraged to recommend members who may benefit from these programs. To verify patient eligibility, check the Eligibility and Benefits Inquiry selection in Availity Essentials.

To recommend patients to Highmark behavioral health programs, providers should call Highmark Behavioral Health Services at:

• Pennsylvania Western and Northeastern Regions: 800-258-9808
• Pennsylvania Central Region: 800-628-0816
• Pennsylvania Southeastern Region: 800-628-0816
• Delaware: 800-421-4577
• West Virginia: 800-344-5245
• New York: 877-878-8785, Option #2

4.2 Accessibility Expectations for Behavioral Health

Accessibility Expectations

To stay healthy, members must be able to see their providers when needed. To support this goal, we are sharing Highmark’s expectations for accessibility of behavioral health providers in an office and outpatient facility setting. The standards set forth specific time frames in which network providers should respond to 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 Pennsylvania Children’s Health Insurance Program (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.

4.2 Treatment Information and Patient Privacy

Consent is Required for Release of Treatment Information

Under federal and state laws, providers of substance abuse and mental health treatment may be required to obtain members’ written consent before releasing certain mental health and substance abuse information to insurers and/or to other health care providers for the management of patient care.

As a contracted provider, it is your responsibility to obtain appropriate consent for release of information.

Restrictions On Substance Abuse Information

Pennsylvania Code Subsection 255.5(b) limits the substance abuse treatment information providers can release to an insurer, even with written member consent. Providers practicing in Pennsylvania are advised to ensure that the information they communicate to Highmark Behavioral Health Services is compliant with these regulations.

Restrictions On Substance Abuse Information

When practicing in any of Highmark’s service areas, contracted providers are expected to be compliant with any applicable federal or state regulations.

4.2 Behavioral Health Provider and PCP Communication

Patient care and clinical outcomes are enhanced when health care professionals share information and coordinate patient care. Communication between behavioral health providers and PCPs is vital, especially when medications are prescribed or changed, or when counseling is provided.

Open and timely communication is particularly important considering that members may contact their behavioral health providers without coordinating care with PCPs.

Member Consent

The member’s consent may be required to permit the behavioral health provider to release certain information to the PCP. The member should be informed of your policy about sharing information with other health care professionals involved in coordinating treatment.

If a patient refuses to give consent, the behavioral health provider should document this refusal in the patient’s behavioral health treatment record.

Member's Role in Communication

Neither PCPs nor behavioral health providers should require members to take responsibility for communicating findings, reports, lab results, etc. to another provider.

Behavioral Health Provider and PCP Communication Procedure

Highmark’s network participating behavioral health providers and PCPs are encouraged to communicate with one another to ensure continuity and coordination of care for members.

PCPs and behavioral health providers should communicate in the following ways to ensure continuity of patient care, provided patient consent has been granted:

• If the PCP has referred (or directed) the member to a behavioral health provider, the PCP should provide relevant clinical information to the behavioral health provider before the member’s visit to the provider. Acceptable forms of communication are formal letter and/or copies of relevant portions of the patient’s medical chart.
• Within one week after the second visit and/or after changes in the member’s treatment or condition, the behavioral health provider should provide the PCP with information about his or her visit with the member, with the member’s consent if applicable, using the same forms of communication.
  

What Should be Communicated?

The following list indicates the type of information that may be communicated:

• Clinical findings/diagnosis (include written description in addition to diagnosis code)
• Test results
• Treatment plans
• A summary report at the conclusion of the treatment period

Form Available for PCP Communication

The Communication Document for Behavioral Health Specialists to Primary Care Physician has been developed to help the behavioral health provider communicate clinical information to the PCP. This form is also available on the Provider Resource Center's Behavioral Health Forms page.

The form is not required. Behavioral health providers can choose to communicate all the information included on the form via another written format. Acceptable formats include typed letters, physician forms, and progress notes.

4.2 Documentation Standards for Outpatient Services

When providing outpatient behavioral health services to Highmark members, progress notes must be documented for each office visit or encounter. Clinical documentation should be created at the time of services and/or before a claim is submitted to Highmark.

Initial Evaluations

Initial evaluations must have a comprehensive history, full mental status exam, and a treatment plan documented. If the services are performed by a licensed or certified therapist under the supervision of an eligible professional provider, the initial evaluation must include the signature of the supervising provider.

Minimum Documentation Standards for Outpatient Office Visits

The provider’s progress notes for outpatient office visits should, at a minimum, include the following information:

• Member’s name
• Date of service
• Length of session (if billing code submitted is time-dependent)
• Therapy/modality utilized
• Appropriate subjective and objective data
• Assessment
• Treatment plan

4.2 Inpatient Consultations for Patients on Medical Units

Determining Whether Authorization is Required

Some patients admitted to a medical unit may require a psychiatric consultation. Whether authorization is required for an inpatient consultation depends on the credentials of the performing provider: 

4.2 Follow-Up Appointments After Hospitalization

Ensuring that behavioral health patients receive appropriate care after an inpatient stay can be challenging. Patient failure to keep an initial outpatient appointment following discharge has been linked to a high risk of relapse and re- admission.

Therefore, Highmark has been working to help members who receive such treatment stay connected to the behavioral health care network following discharge in an effort to improve their health and quality of life.

Discharge Planning

Discharge planning should begin prior to or upon admission to an inpatient facility. At the time of precertification, the behavioral health care manager discusses discharge planning barriers and assists with any discharge needs.

Follow-Up Appointment Important

To increase the likelihood that a member being discharged from inpatient behavioral health services will receive appropriate aftercare, it is very important that the member leave the hospital with a follow-up outpatient appointment.

Member Contact After Inpatient Discharge

Upon a mental health inpatient discharge, a Highmark behavioral health specialist will attempt to make a post-discharge call to the member. When post-discharge contact is made, the behavioral health specialist will verify that a follow-up appointment has been made or, if necessary, assist the member in obtaining an appointment.

The behavioral health specialist will provide education about the importance of adhering to scheduled appointments and will work with the member to resolve any barriers. They will also discuss any questions the member may have regarding discharge instructions, medication changes, and/or any other issues of concern to the member.

When Medication is Prescribed

The follow-up appointment is particularly important when a patient is discharged with a prescription for psychotropic medication. Follow-up care should be arranged with a behavioral health provider.

If a Follow-Up Appointment is Not Made

If a member leaves an inpatient facility without an appointment for any reason, the Highmark behavioral health specialist will assist the member with obtaining follow-up services. 

Continuing Care Coordination

Highmark is committed to working with providers to support members in maintaining the gains made during their inpatient treatment. If the member does not keep the scheduled follow-up appointment, please make every effort to reschedule as soon as possible.

4.2 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.

4.3 Overview of Facility-Specific Guidelines

4.3 Member Access to Facilities

4.3 Status of Patient vs. Place of Service

4.3 Guidelines of Billing Ambulance Transports Between Hospitals

4.3 Observation Services

4.3 Purchased Services Provided to Members Registered as Inpatients or Outpatients

4.3 Post-Exposure Rabies Treatment

4.3 Early Maternity Discharge and Home Health Evaluation

4.3 Breast Pumps and Lactation Counseling

4.3 Disclaimers

4.3 Overview of Facility-Specific Guidelines

A facility provider is a hospital, ambulatory surgery center, home health agency, hospice, home infusion agency, skilled nursing facility, an alcohol or drug treatment center, or other facility that is licensed or certified to perform designated, covered health care services by the state or jurisdiction where services are provided.

This unit includes facility-specific guidelines for facility providers and applies to Commercial and Medicare Advantage, unless otherwise noted. Section headings will help to identify if the information in the section is applicable to a specific facility type.

Medicare Advantage

For guidelines related to care management of Medicare Advantage members, please see Chapter 5.3: Medicare Advantage Procedures.

4.3 Member Access to Facilities

Availability of Facility Services

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

Access to Physician Services

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 the physician has the appropriate training, education, and licensure to provide such services.

Equal Access and Non-Discrimination in Treatment of Members

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

Facilities will provide members with equal access at all times to facility services. Facilities 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, facilities shall not deny, limit, discriminate or condition the furnishing of facility 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.

4.3 Status of Patient vs. Place of Service

Policy

When a member who is an inpatient or outpatient of a hospital is taken outside of the hospital (e.g., MRI or CT mobile unit or doctor’s office) for a procedure and is then returned to the hospital without being discharged, the service should be classified as inpatient or outpatient based on the status of the patient at the hospital versus the place where the service was performed.

Patient Status Definitions

The definition of the status of the patient is as follows:

Inpatient – A patient is considered an inpatient if formally admitted as an inpatient in a facility, such as a hospital or skilled nursing facility, at the time the procedure is performed.

Outpatient – A patient, other than inpatient, who is treated in a hospital, on hospital grounds, or in a hospital-owned or controlled satellite. This definition does not apply when a treating physician’s sole practice is located in a hospital or hospital-owned building, and when the practice is not affiliated or controlled, in any way, by the hospital or related entity.

Reminder: Observation status is an outpatient care option that can be used when a member's condition must be evaluated promptly, but appropriateness of an inpatient admission has not yet been confirmed. For more information, please see the applicable section on Observation Services in this unit. 

4.3 Guidelines of Billing Ambulance Transports Between Hospitals

The guidelines below are for billing ambulance transports between hospitals, including one-way transports and transports with return to the original facility.

One Way Transports

When a member must be transported from Hospital A to become an inpatient of Hospital B, that member has in effect been discharged from Hospital A. Since the member is no longer an inpatient at the time of transport, this service can be provided and billed by a network participating ambulance provider or any other licensed ambulance transport provider (including a hospital-based ambulance service).

Assuming that the member has coverage and the necessary benefit and that the claim is billed appropriately, payment will be made to the ambulance provider in accordance with the member's benefit plan and, if applicable, the provider's Highmark contract.

Note: If a member arrives in the emergency room, is stabilized, and then transferred to another hospital without being admitted, the claim would also be billed by the ambulance transport provider.

Emergent Situations Arising While an Inpatient

There may be situations in which a member who is an inpatient at one facility is transported on an emergency basis to another facility. In these instances also, any licensed ambulance transport provider, including a network participating ambulance provider or a hospital-based ambulance service, may transport the member.

Unless the member is later returned to the original facility, which would be unusual in these circumstances, he or she would not be considered an inpatient at the time of transport. Therefore, the services must be billed to Highmark by the ambulance transport provider.

Again, assuming that the member has coverage and the necessary benefit and the claim is billed correctly, payment will be made to the ambulance transport provider in accordance with the member's benefit plan and, if applicable, the provider’s Highmark contract.

Transport with Return

There are situations in which the member is admitted to Hospital A but must be transported via ambulance to Hospital B to receive specialized services (e.g., an MRI) not available at Hospital A. After the services have been provided, the member is returned to Hospital A.

In such situations, the member is considered an inpatient of Hospital A throughout this sequence of events, including the roundtrip transport. As a result, the ambulance transport services are considered to be part of Hospital A's inpatient claim. The services can be provided by a network participating ambulance provider or any licensed ambulance provider, which must then bill the hospital for the transport.

Hospital A must include the ambulance charge on the corresponding inpatient claim to Highmark. The services will be reimbursed within the hospital's DRG or per-diem payment for the inpatient stay, in accordance with the member's benefit plan. No separate payment (apart from the DRG or per-diem payment to the hospital) will be made to the hospital or the ambulance provider by Highmark for the ambulance transport services. The hospital is responsible for reimbursing the ambulance provider. 

4.3 Observation Services

Observation status is an outpatient care option that can be used when a member's condition must be evaluated promptly but appropriateness of an inpatient admission has not yet been confirmed.

Highmark encourages hospitals to perform the appropriate diagnostic services promptly so the determination can be made on an expedited basis.

Definition: Outpatient Observation Services — From Centers for Medicare and Medicaid Services (CMS)

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.

Hospitals may also bill for patients who are directly referred to the hospital for outpatient observation services. A direct referral occurs when a physician in the community refers a patient to the hospital for outpatient observation, bypassing the clinic or emergency department visit.

Time Frame for Observation Services

Highmark recognizes that most observation services do not exceed one day and in rare instances span beyond 48 hours. For purposes of reimbursement, Highmark will not reimburse for observation services that exceed 48 hours.

Note: Observation services begin at the time the physician writes the order for outpatient observation. The reason for observation must also be stated in the orders.

Goal of Observation

Observation status does not replace or extend outpatient ambulatory diagnostic or therapy services, nor is it to be used in conjunction with elective outpatient surgery, including post-procedure observation.

Observation is meant to be used for making a diagnosis and/or treating a patient in an acute-care facility prior to or instead of an inpatient admission.

Medicare Outpatient Observation Notice (Moon)

On August 6, 2015, Congress passed the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which requires all hospitals and critical access hospitals (CAHs) to provide written and oral notification to all Medicare beneficiaries receiving observation services as outpatients for more than 24 hours. The written notice must include the reason the individual is receiving observation services, and must explain the implications of receiving outpatient observation services, in particular the implications for cost-sharing requirements and subsequent coverage eligibility for services furnished by a skilled nursing facility.

The Medicare Outpatient Observation Notice (MOON) was developed by the Centers for Medicare and Medicaid Services (CMS) to serve as the standardized written notice. Beginning March 8, 2017, the MOON must be presented to Medicare beneficiaries, including those with Medicare Advantage plans, to inform them that the observation services they are receiving are outpatient services and that they are not an inpatient of the hospital or CAH. Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged, or admitted.

The hospital or CAH must obtain the signature of the patient or a person acting on behalf of the patient (“representative”) to acknowledge receipt of the notification. If the individual or representative refuses to sign it, the written notification is signed by the hospital staff member who presented it.

The CMS-approved standardized MOON form (CMS-10611) and accompanying instructions are available on the CMS website. 

Typical Uses for Observation

Although Highmark does not restrict coverage of observation services to particular medical conditions, observation services are for urgent or emergent medical conditions. Observation is only medically necessary when the patient's current condition requires outpatient hospital services, or when there is a significant risk of deterioration in the immediate future such that continued observation in a non-hospital environment is inadvisable.

The following circumstances typically warrant the use of observation:

• The hospital expects that the patient will be stabilized and released within 48 hours.
• The clinical diagnosis and necessity of inpatient admission are unclear, but the hospital expects to determine these in less than 48 hours. 

Inappropriate Uses for Observation Status

It is inappropriate to place a patient in observation status for any of the following reasons:

• Patient, physician, or hospital convenience
• Respite care
• Pre-operative preparations or evaluations that do not meet criteria for acute-care facility admissions
• Pre-procedure care for diagnostic procedures that do not meet criteria for acute-care facility admission
• Post-procedure care for diagnostic procedures

Medical Policy V-3

For additional information on medical necessity and documentation requirements, please see Highmark Commercial Medical Policy V-3: Billing of Observation Services.

Outpatient Cost-Sharing Applies

Many Highmark benefit plans currently include member cost-sharing for outpatient hospital services, including those received in the emergency room. Under most benefit plans, this cost-sharing requirement is waived if the member is admitted as an inpatient.

When members come into a hospital through the emergency room, it often is not immediately clear whether they need to be admitted as an inpatient and the member may be placed in observation status. If a member is not truly admitted as an inpatient to the hospital, then the member is responsible for any applicable outpatient cost-sharing amounts indicated by their benefit plan.

EXAMPLE: The member is placed in observation status after being treated in the emergency room. After treatment in observation, the member is discharged to his or her home the following afternoon. The member has a $50 emergency room copayment. Since the member was not admitted as an inpatient, he or she would be responsible for the $50 emergency room copayment.

Because observation services can be provided in any room or bed in a hospital, and because the member often stays in the facility overnight and may be served a meal, it may seem to the member and family that he or she is receiving inpatient care. If it is eventually determined that the member's condition does not meet MCG Care Guidelines and he or she can safely be discharged to home, the member or family may be surprised to learn that the services received throughout the time spent in the hospital were actually classified as outpatient in nature. Because of this confusion, members may dispute their obligation to pay the cost-sharing amounts for which they are in fact responsible.

The most important step that hospitals can take to assist their own facility in collecting member cost-sharing amounts is to inform the member, and/or the family, that the services received were observation services -- not an inpatient admission. In an effort to educate members, Highmark has published articles about observation services in its member newsletters.

Hospitals are welcome to use the article as they choose to help Highmark members understand that observation services are classified as outpatient in nature and that if they receive such services and are not formally admitted as inpatients, they are responsible for the outpatient cost-sharing amounts required by their benefit plan.

EXCEPTION: Please note that this request is not applicable to situations in which the member is in fact admitted as an inpatient following observation.

Requesting an Inpatient Admission

The hospital can request authorization of an inpatient admission as soon as clinical findings indicate that the admission would be appropriate. This can occur at any point during the observation period. There is no need to wait until 48 hours have elapsed.

The request for the inpatient authorization should ordinarily be made using Availity. If Availity is unavailable, contact Highmark Clinical Services at:

• In the PA Western Region, call 800-242-0514.
• In the PA Central and Northeastern Regions, call 866-803-3708.
• In the PA Southeastern Region, call 800-628-0816.
• In the Delaware, call 800-572-2872.
• In the West Virginia, call 800-344-5245.

Important! Always Confirm Benefits

Availability of benefits under the member's benefit plan is required in order for a service to be reimbursed by Highmark. Be sure to confirm the specific member cost-sharing responsibility for outpatient services for each member.

Availability of benefits can be verified through the Eligibility and Benefits Inquiry function in Availity. If Availity is unavailable, providers may contact the appropriate Highmark Provider Service unit by telephone.

Reporting Observation Services

Observation services are reported in Pennsylvania and West Virginia using the following revenue and procedure codes:

When the patient was admitted directly to Observation, the hospital should report procedure code G0379 (Direct Referral to Observation), in addition to procedure code G0378. In such situations, payment for the services will be made on the basis of the presence of procedure code G0378 on the claim. No payment will be made based on the presence of procedure code G0379.

As required by the definition of the procedure code, units must equal the hours of observation services provided. Observation hours should be rounded to the nearest minute, as directed below:

The claim for observation services must include one of the following services in addition to the reported observation services. The additional services listed below must have a line item date of service on the same day or the day before the date reported for observation:

• Type A or Type B emergency department visit (CPT codes 99281-99285 or HCPCS codes G0380-G0384); or
• Clinic visit (HCPCS code G0463); or
• Critical care (CPT code 99291); or
• Direct referral for observation care reported with HCPCS code G0379 (APC 5013) must be reported on the same date of service as the date reported for observation services.

Hospitals are reminded that observation services resulting in an inpatient admission are to be reported on the inpatient claim and are reimbursed via the payment for the inpatient stay. No separate reimbursement will be made for the observation services.

Important !

Highmark Delaware providers need to follow their current reimbursement method and continue to submit claims according to their contract.

4.3 Purchased Services Provided to Members Registered as Inpatients or Outpatients

When a Highmark member is registered as an inpatient or an outpatient at a participating facility, the facility is responsible to provide or arrange for all of the care and services the member receives during that stay or visit. This section is meant to clarify Highmark's policy and procedure for providing services and/or dispensing supplies and/or equipment to Highmark members when they are registered as inpatients or outpatients

Purchased Services Defined

If a participating facility is not able to provide (or chooses not to provide) a particular service or supply to Highmark members when they are registered as inpatients or outpatients, then the facility must make the appropriate arrangements with another entity/vendor to provide those services.

The key to understanding this requirement is not the type of service — but the entity providing the service. If a facility does not have the proper equipment or expertise to provide a given service, and engages with an outside vendor to render it, then that service by definition is called a purchased service.

Examples of purchased services include, but are not limited to, the following:

• Durable medical equipment, orthotics, prosthetics, and supplies (DMEPOS)
• Laboratory and pathology services
• Cardiac event monitors

Limited Reimbursement

Additional reimbursement is very limited, and most services, supplies, and equipment are not eligible for separate payment and are considered to be inclusive of your consolidated payment from Highmark. It is important to reference your Highmark contract to determine your specific reimbursement methodology and continue to submit claims accordingly.

Using Vendors

If a vendor has been engaged by your facility to provide certain services or supplies to a Highmark member registered as an inpatient or outpatient at your facility, and the services or supplies are not eligible for separate payment, then it is your responsibility to enter into a financial arrangement to pay this vendor for the services or supplies provided.

The vendor may not bill Highmark — or the member — directly, and your facility is obligated to reimburse the vendor according to the financial arrangement made between your facility and the vendor. Highmark is not responsible and will not make a separate payment to the vendor.

Note: Contracted facilities may bill the member for cost-sharing amounts (deductible, coinsurance or copayment) as required by the member's benefit plan.

Certain Supplies Billable to Highmark

When a Highmark member is registered as an inpatient or outpatient at a participating facility, certain supplies are considered billable and eligible for separate payment ONLY when one of the following apply:

• The equipment or supplies requires approval and authorization by Highmark's Clinical Services; or
• The equipment or supplies are customized specifically for the individual member’s use in the home setting (e.g., customized power wheelchairs, customized splints or braces provided to the member for use in the home).

Note: In this instance, DMEPOS providers may bill Highmark directly, but only for the equipment/supplies as outlined above. Any other DMEPOS provided are not eligible for separate reimbursement, and claims should not be submitted directly to Highmark.

Exceptions for Medicare Advantage

When a Medicare Advantage member is registered as an inpatient or outpatient at a participating facility, certain clinical laboratory services are considered billable. Chemotherapy sensitivity tests performed on live tissue are the only laboratory services billable and eligible for separate payment from Highmark. In this instance only, reference laboratories are permitted to bill and seek payment from Highmark directly.

Highmark's purchased service policy does not apply in the case of DMEPOS items provided to Medicare Advantage members residing in a SNF who have exhausted their 100-day skilled nursing benefit or are receiving a non-skilled level of care. Under these circumstances only, the billing process should be treated as if the member is living in his or her own residence. Therefore, the DMEPOS provider would bill the claim to Highmark directly.

4.3 Post-Exposure Rabies Treatment

The Centers for Disease Control and Prevention (CDC) recommends the following regimen for post-exposure rabies treatment:

• Wound Cleansing: All post-exposure prophylaxis should begin with immediate thorough cleansing of the wound.
• Rabies Immune Globulin (RIG): RIG is administered to provide immediate antibodies until the body can respond to the vaccine; this is given only once on the day of exposure (day 0) and should not be administered to previously immunized individuals.
• Vaccine: Injections of the rabies vaccine are given on days 0, 3, 7, and 14; a fifth dose on day 28 may be recommended for immunocompromised persons. Previously vaccinated individuals should receive two doses, one immediately and one three days later.

Place of Service

Post-exposure rabies treatment can be sought from a hospital, PCP, urgent care centers, or the Health Department. However, rabies immune globulin (RIG) and rabies vaccine may not be readily available at physicians’ offices or locations other than hospitals. Because of the need for timely treatment, individuals most often will seek initial treatment in a hospital emergency room and return to the hospital to complete the vaccine series.

Reporting Services

Hospitals are to report post-exposure rabies treatment as indicated below.

Initial Visit in the Emergency Room

• Revenue Codes: 450 (Emergency Room); 250 (Pharmacy)
• Procedure Codes:
  • Rabies Immune Globulin (RIG)
    • 90375 – Rabies immune globulin (RIG), human, for intramuscular and/or subcutaneous use; or 
    • 90376 – Rabies immune globulin, heat-treated (RIG-HT), human, for intramuscular and/or subcutaneous use
  • Rabies Vaccine
    • 90675 – Rabies vaccine, for intramuscular use; or 
    • 90676 – Rabies vaccine, for intradermal use
• Appropriate ICD-10 diagnosis code(s) for the exposure.

Follow-Up Visits for Rabies Vaccine

• Appropriate revenue codes, such as:
  • 510 (Clinic – general)
  • 761 (Treatment Room)
  • 771 (Preventive care services vaccine administration)
• Procedure Codes:
  • 90675 – Rabies vaccine, for intramuscular use; or
  • 90676 – Rabies vaccine, for intradermal use
• Appropriate ICD-10 diagnosis code(s) for the exposure.

Reimbursement and Member Cost Sharing

Reimbursement is subject to medical necessity and the benefits available under the member’s benefit plan at the time of service. Providers are reminded to always confirm a member's eligibility and benefits prior to rendering services.

Contracted facilities may bill the member for cost-sharing amounts (copay, deductible, coinsurance) as applicable under the member's benefit plan.

4.3 Early Maternity Discharge and Home Health Evaluation

Newborns’ and Mothers’ Health Protection Act (NMHPA)

The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) is a federal law that affects the length of time a mother and newborn child are covered for a hospital stay in connection with childbirth. Group and individual health plans subject to NMHPA may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section.

If the baby is delivered in the hospital, the 48-hour or 96-hour period starts at the time of delivery. If the baby is delivered outside the hospital and later admitted to the hospital in connection with childbirth (as determined by the attending physician) the period begins at the time of admission.

If the attending physician, in consultation with the mother, determines that the mother or the newborn child can be discharged before the 48-hour or 96-hour period, the health plan does not have to continue covering the stay for the one ready for discharge.

The federal NMHPA does not require follow-up visits. Some states, however, mandate expanded coverage for shorter lengths of stay.

Pennsylvania Health Security Act 85 of 1996 

The General Assembly of the Commonwealth of Pennsylvania enacted the Health Security Act in 1996 (Act 85). This Act applies only to Highmark health insurance policies that provide maternity benefits and are issued through Highmark plans located in Pennsylvania.

As in the NMHPA, Pennsylvania’s Act 85 also requires that every health insurance policy that provides maternity benefits to provide coverage for a minimum of 48 hours of inpatient care following normal vaginal delivery and 96 hours of inpatient care following cesarean delivery. Act 85 also provides for a shorter length of stay if the treating or attending physician determines that the mother and newborn meet medical criteria for safe discharge.

In addition to minimum maternity stay requirements, Act 85 provides coverage for at least one home health care visit within 48 hours after discharge when discharge occurs prior to 48 hours following a vaginal delivery or 96 hours following cesarean delivery. The visit must be provided by a licensed health care provider whose scope of practice includes postpartum care.

The initial home health visit following discharge should be used to verify the condition of the infant and the mother. The initial visit does not require authorization. Any additional visits, if needed, require authorization and should be coordinated by the home health agency (HHA)

Eligibility and Benefits

When coordinating a home health visit following an early maternity discharge, providers should first check the member's eligibility and benefits using Availity's Eligibility and Benefits Inquiry to determine if their coverage follows the mandate.

Pennsylvania’s Act 85 is tied directly to the maternity benefit.

Authorization Requirements

HHAs are reminded that authorization is not required for the initial evaluation of the mother and baby when the group has elected to follow the mandate and meets the criteria for early discharge. Any additional visits, if needed, require authorization and should be coordinated by the HHA.

If the member's coverage does not follow Act 85 or the length of stay does not fall within the designated time frames, the HHA must check for the availability of home health benefits. If coverage is available for home health care, each visit may require authorization.

Scenarios

The table below reviews several scenarios and clarifies when authorization is required for home health visits following a maternity stay:

Claims Rejected for Auth in Error

If a claim is rejected for no authorization when an authorization is not required based on the scenarios above, the HHA should submit a Secure Message via Availity.

4.3 Breast Pumps and Lactation Counseling

Under the Affordable Care Act of 2010 (ACA), specific women's preventive health care services are required to be covered for eligible health plan members without cost sharing to members. Such services include breastfeeding support, supplies, and lactation counseling services.

Coverage at a Glance

Breastfeeding support, counseling, and supplies are covered ACA Women’s Preventive Health Services Mandate with no cost-sharing to the member when performed by in-network providers.

• Out-of-network coverage is pursuant to the terms of the member's individual benefits.
• Out-of-network cost sharing and balance billing may apply.
• Only durable medical equipment (DME) providers can bill for breast pumps and supplies.

Verify Eligibility and Benefits

You can verify whether a Highmark member is covered under the federal Women’s Preventive Health Mandate via Availity's Eligibility and Benefits Inquiry or the applicable HIPAA electronic transactions.

Breastfeeding Pumps and Supplies

Breastfeeding pumps and supplies are covered without cost sharing for women covered under the ACA Women’s Preventive Health Services Mandate. Eligible members are entitled to one breast pump per pregnancy when supplied by any network participating durable medical equipment supplier.

Eligible Highmark members can order high-quality breast pumps directly from two of the leading manufacturers in the industry: Ameda and Medela. Members can call the selected manufacturer or place an order online in advance of their delivery. The manufacturer will confirm a member’s eligibility and submit claims to Highmark for processing. Eligible members can be directed to contact the manufacturers as follows: 

Breastfeeding Supplies Procedure Codes

For eligible members whose coverage falls under the ACA women’s health mandate, breast pumps and supplies are covered without member cost sharing when provided by participating DME providers. The following are eligible procedure codes for breastfeeding pumps and supplies:

Lactation Counseling/Support

Based on the ACA mandate, lactation services are eligible with no member cost sharing as follows:

• When provided by credentialed physicians who can employ lactation consultants or use their nursing staff to provide support. (This includes services provided by a physician assistant [PA] or certified registered nurse practitioner [CRNP] when under the supervision of a credentialed physician. Lactation consultants are not credentialed and cannot receive direct payment for their services.)
• When billed using the appropriate procedure codes — 99401, 99402, and 99403 — and the appropriate diagnosis code of Z39.1.

Additionally, breastfeeding counseling/support is eligible with no age limit or frequency restrictions, and lactation counseling/support is considered to be a preventive service.

Please also note the following:

• When the service is provided by the pediatrician, then it is integral to the baby exam.
• When a lactation consultant provides the service in the pediatrician office, the billing is for the mother.
• When the services are provided as part of the maternity hospitalization, the payment is bundled and paid per the facility contract and integral to that admission.
• The service is part of the standard preventive schedule for non-grandfathered groups (NGF); please check Availity for benefit coverage.

For More Information

Highmark Medical Policy E-37 includes medical guidelines not outlined in the ACA mandate; however, these medical policy guidelines would apply to those groups that do not follow the Women’s Health Federal Mandate. The policy addresses:

• Newborns who are detained in the hospital after the mother is discharged
• Babies who have congenital anomalies that interfere with feeding Highmark Medical Policy can be accessed from the Provider Resource Center by selecting Policies and Programs from the main menu.

4.3 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.

4.4 Introduction

4.4 West Virginia Senate Bill 273 - Alternative Treatments for Management of Chronic Pain

4.4 Ground Ambulance Services

4.4 DME/Respiratory Supplies Management Program

4.4 Authorizing Durable Medical Equipment

4.4 Billing for DMEPOS Provided to Members Registered as Inpatients or Outpatients at a Facility

4.4 Home Infusion Therapy Guidelines

4.4 Medicare Advantage Guidelines for DMEPOS Upgrades

4.4 Medicare Advantage Home Oxygen Therapy

4.4 Diabetic Testing Devices for Medicare Advantage Members

4.4 Disclaimers

4.4 Introduction

Ancillary care refers to the wide range of health care services provided to support the work of physicians. To supplement the professional provider and facility networks, Highmark contracts with a network of ancillary providers that provide health care related equipment or services. These include freestanding and facility-based providers in specialties including, but not limited to:

• Durable medical equipment and supplies
• Orthotics/prosthetics
• Home infusion
• Ambulance
• Diagnostic services (radiology and laboratory)
• Therapeutic services (i.e., physical and occupational therapy, chiropractic services, and speech therapy)

In this Unit

This unit provides information and guidelines for providers of ancillary services such as durable medical equipment and supplies, orthotics, prosthetics, home infusion, therapy services, and more.

For diagnostic services, see Chapter 4.5: Outpatient Radiology and Laboratory.

Network Participation

For information on applying to participate in Highmark’s facility and ancillary networks, see Chapter 3.4: Organizational Provider Participation.

4.4 West Virginia Senate Bill 273 – Alternative Treatments for Management of Chronic Pain

West Virginia Senate Bill 273 (the “Act”), effective June 7, 2018, was enacted in an effort to reduce opioid addiction by requiring health care insurers licensed in West Virginia to provide coverage for certain alternative treatments for management of chronic pain. The Act, in relevant part, amends Chapter 16 of the West Virginia Code relating to Public Health to add §16-54-1 et seq. (Treatment of Pain).

Requirements Under the Act

The following is a summary of the Act’s requirements:

• A health care practitioner can refer or prescribe any of the following treatment alternatives when a patient seeks treatment for chronic pain, based on their clinical judgment and the availability of the treatment, before starting a patient on an opioid: physical therapy, occupational therapy, acupuncture, massage therapy, osteopathic manipulation, chronic pain management program, and chiropractic services.
• All of these treatment alternatives do not need to be exhausted before prescribing an opioid.
• A practitioner may simultaneously prescribe an opioid along with any of the alternative treatments listed above.
• An insurer must provide, at a minimum, coverage for twenty (20) visits per event of physical therapy, occupational therapy, osteopathic manipulation, a chronic pain management program, and chiropractic services to treat conditions that cause chronic pain when ordered by a health care practitioner.
• A provider referral is not required as a condition of coverage for patients seeking these services.
• Any deductible, coinsurance, or copayment for these services may not be greater than the deductible, coinsurance, or copayment required for a primary care visit.

Applicability

Beginning with benefit plans renewing July 1, 2018, the Act will apply to Highmark West Virginia fully insured large group and small group products, as well as Medicare supplemental group (Medifil) and individual (Medigap Blue) plans, upon renewal. The group products will continue to renew with the change through June 1, 2019.

Self-insured employer groups will be offered the opportunity to opt in and may or may not elect to follow the requirements of the Act.

The Act becomes effective on January 1, 2019, for individual Affordable Care Act (ACA) products, both on and off the Exchange.

Verify Benefits

To determine whether a member has coverage for alternative treatments for managing chronic pain as indicated under the Act, be sure to verify the member’s benefits via Availity's Eligibility and Benefits Inquiry prior to providing services.

If the Act applies to a member’s benefit plan, it will indicate “Yes” for WV Mandate – Opioid Reduction Act (SB 273) under Product Wide Provisions. Benefit categories with special guidelines for visit limits per event for chronic pain include physical medicine, occupational therapy, and spinal manipulations.

Definitions

Chronic pain is defined as a non-malignant, non-end-of-life pain lasting more than three months or longer than the duration of normal tissue healing. Pain is considered chronic if it persists longer than expected after an illness or injury, if it is associated with a chronic pathological process, or if it flares up periodically over months to years.

Chronic pain may be caused by physical, psychological, and environmental factors. Chronic non-malignant pain encompasses many painful disorders including but not limited to back pain, migraine headaches, diabetic neuropathy, dental and orofacial pain, and arthritic pain.

An event is defined as an adverse or damaging medical occurrence resulting in an acute exacerbation of an existing chronic pain condition.

Chronic Pain Management Services

For following guidelines apply for chronic pain management services:

• The services must be provided in an outpatient setting, and
• The patient must have a diagnosis of chronic pain, and
• The patient must have an adverse or damaging medical occurrence resulting in an acute exacerbation of an existing chronic pain condition.

Applicable Diagnosis Codes

The Act applies to the following ICD-10-CM Primary Diagnosis Codes:

• G89.21 – Chronic pain due to trauma
• G89.28 – Other chronic post-procedural pain
• G89.29 – Other chronic pain
• G89.4 – Chronic pain syndrome 

How Visit Limits Apply Per Event

The chronic pain visit limit per event is applied as a combination of physical therapy, occupational therapy, chiropractic services, osteopathic manipulation, and chronic pain management programs (and not as a visit limit per each service per event). Any combination of these services will fulfill the “per event” visit limit. In addition, the visit limits are combined for services provided in-network and out-of-network.

Note: Services received for diagnoses other than chronic pain will not apply to a member’s visit limit per event coverage for chronic pain. Review the member’s benefits via Availity’s Eligibility and Benefits Inquiry for these services when they are provided for diagnoses other than chronic pain.

Highmark West Virginia Medical Policy

Refer to the following Highmark West Virginia medical policies for physical and occupational therapy and manipulation services:

• Y-1 Physical Medicine
• Y-2 Occupational Therapy (OT)
• Y-9 Manipulation Services

In addition, see Highmark West Virginia Medical Policy Y-23 Chronic Pain Management, effective Sept. 17, 2018. This policy is applied on a post-payment basis and services will be subject to retrospective review.

Highmark West Virginia Medical Policy can be accessed under Policies and Programs from the main menu.

4.4 Ground Ambulance Services

The purpose of this section is to provide Highmark’s guidelines for billing ground ambulance services for all commercial products. When used here, the term “ambulance transport services” includes all medically necessary ambulance services, except wheelchair van transport.

Medical Necessity

To be eligible for approval and payment, ambulance transport services must be medically necessary and appropriate. Medically necessary ambulance services are those rendered when the patient’s clinical condition is such that the use of any other method of transportation, such as a taxi, personal car, or other type of vehicle, would be contraindicated (e.g., it would endanger the member’s health).

Benefits

Although many Highmark benefit plans provide benefits for medically necessary ambulance transport services, benefits vary widely. The coverage available to any particular member is determined by the member’s specific benefit plan.

For medically necessary ambulance transport services provided to Highmark members, payment is made in accordance with the member’s benefit plan and, if applicable, the provider’s contract if the required benefit is available and the claim is billed appropriately.

Highmark’s determination on which entity is to bill for ambulance transport services is based on the Medicare program’s distinction between Part A and Part B services as in the table below. This standard applies to all Highmark products:

Emergent Situations

In the case of an emergency, any licensed ambulance transport provider (including a hospital-based service) may transport a Highmark member with coverage under any product from the scene of an accident or other initiating event to the closest facility that can provide the needed services.

• When the member is not an inpatient of any facility at the time of transport, the services must be billed to Highmark by the ambulance provider.
• If a member is an inpatient at one facility and is transported to another facility on an emergency basis, any licensed ambulance transport provider may transport the member. Unless the member is later returned to the original facility (which would typically be unusual in these circumstances), the member would not be considered an inpatient at the time. Therefore, the services must be billed to Highmark by the ambulance provider.

Assuming the member has coverage and the necessary benefit and that the claim is billed appropriately, payment will be made in accordance with the member’s benefit plan.

Non-Emergent Situations: To and From Hospitals

When a member must be transported from Hospital A to Hospital B, that member has been discharged from Hospital A. Since the member is no longer an inpatient at the time of transport, this service can be provided and billed by any licensed ambulance transport provider (including a hospital-based ambulance service). Assuming that the member has coverage and the necessary benefit and that the claims is billed appropriately, payment will be made in accordance with the member’s benefit plan and, if applicable, the provider’s Highmark contract.

Non-Emergent Inter-Hospital Transports with Return

If a member is transported from Hospital A to Hospital B to receive specialized services not available at Hospital A, and then returns to Hospital A, the member is considered an inpatient of Hospital A throughout the events, including the transport.

The ambulance transport services are part of Hospital A’s inpatient claim. The services can be provided by any licensed ambulance provider, which then must bill the hospital for the transport.

4.4 DME/Respiratory Supplies Management Program

Under the Durable Medical Equipment (DME)/Respiratory Supplies Management Program, specific DME and supply items require authorization. Managed care plans typically require authorization — PPO, EPO, HMO, IPA, POS, including Medicare Advantage PPO and HMO plans. However, benefits can vary and certain employer groups may choose to opt out of this requirement; always confirm DME authorization requirements under the member’s coverage. You can use the Availity Essentials® Eligibility and Benefits Inquiry transaction or the applicable HIPAA electronic transaction for benefit verification.

Highmark is responsible for claims processing, utilization management, and authorization functions for DME, prosthetics, orthotics, and supplies provided to Highmark members. Please verify benefits via Availity for a member’s specific coverage.

DME Requiring Authorization

Highmark maintains a List of Procedures/DME Requiring Authorization. This list is available on the Provider Resource Center under Claims and Authorization.

The authorization process for DME and supplies furnished through a stand-alone, Highmark participating ancillary DME suppliers for the items on the list is managed by Highmark’s Clinical Services. Ordering physicians may initiate authorization requests. Availity-enabled providers must submit the authorization request via Availity.

Important

DME that does not require authorization simply requires a prescription written by the ordering physician.

Medicare Advantage

For Medicare Advantage members, all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims that do not require authorization will process according to indications and limitations of Medicare Advantage Medical Policy. Items and services that are not considered to be medically necessary may not be billed to Medicare Advantage members without a Notice of Denial of Medical Coverage from Highmark (obtained through a preservice organization determination).

For information on preservice organization determinations for Medicare Advantage, see Chapter 5.3: Medicare Advantage Procedures.

Claim Submission

Electronic claims submission is the preferred, most efficient, and most cost-effective method of submitting claims. If you are not yet submitting claims to Highmark electronically, visit the Electronic Data Interchange (EDI) Services website. Or call EDI Operations toll-free at 800-992-0246, Monday through Friday, 8 a.m. to 4:30 p.m. EST.

You can also submit claims electronically through Availity's HIPAA-approved claims submission transaction. Once your claims are submitted to Highmark, whether through Availity or a HIPAA 837 electronic transaction, you are able to view the claim status and perform a Secure Message in Availity.

DMEPOS Refills

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the member or caregiver/designee prior to dispensing refills. Highmark does not support or endorse auto-shipping; if the member is enrolled in or gives approval for auto-shipment of their supplies, the provider should not automatically ship the item(s). This is to ensure that the refilled item remains medically necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order.

A refill request must be obtained from a member prior to delivery of any refill items. Refill requests are to be obtained on a monthly basis; refill requests for supplies should not extend beyond 30 calendar days. The member’s refill request, including date of request and supplies requested, must be documented in the provider’s records and provided to Highmark upon request.

Documentation of Trial/Rental Period on CMN/LMN

If a Certificate of Medical Necessity (CMN) or Letter of Medical Necessity (LMN) indicates that a required trial/rental period for a DME item has occurred in the office, the provider must document the dates in which the trial occurred on the CMN/LMN.

If the dates of the in-office trial/rental are not indicated, the DME company is required to proceed as if the trial did not occur and must fulfill the trial/rental period prior to purchase.

4.4 Authorizing Durable Medical Equipment

The steps listed below describe the process to obtain authorization for durable medical equipment, prosthetics, orthotics, and respiratory supplies. Ordering physicians may initiate the authorization request.

This process applies to PPO, EPO, HMO, IPA, POS, and PPO Plus plans (including Medicare Advantage HMO and PPO plans in Pennsylvania and West Virginia).

Step 1: The requesting provider determines whether the request must be authorized by Highmark’s Clinical Services. Please gather all pertinent information, including a Certificate of Medical Necessity (CMN) if required, prior to submitting the request.

Step 2:  If required, the requesting provider submits the request for authorization to Clinical Services through one of the following methods:

• If Availity-enabled, the request must be submitted via Availity.
• For those practices not yet Availity-enabled, fax an authorization request form to 412-544-2921 or 888-236-6321.

Step 3: Clinical Services will review the request.

• If benefits are not available, go to Step 4.
• If medical appropriateness cannot be determined, go to Step 5.
• If the request meets criteria, Clinical Services will approve the authorization request and notify the requester.

Step 4: If benefits are not available for the requested item or service, Clinical Services will deny the authorization request and notify the requesting provider.

 A denial letter from Highmark will be sent to the ordering physician, vendor, and the member. Information regarding appeal/complaint rights will be detailed in the denial letter.

Step 5: If medical appropriateness cannot be determined from the documentation provided, Clinical Services will contact the requesting provider for additional information.

 This information must be returned to Clinical Services in a timely manner, preferably within 48 hours, as regulatory time frames must be met.

 Proceed to Step 6.

Step 6: 

• If medical necessity cannot be determined, the authorization request is pended and sent to a Highmark physician reviewer for review. Proceed to Step 7.
• If the documentation substantiates the request, the service will be approved and the requesting provider will be notified.

Step 7: If the Highmark physician reviewer determines that the authorization:

 Is medically appropriate…

 Clinical Services will approve the pended authorization request and notify the requester.

Is not medically appropriate…

A physician will deny the pended request and send a denial letter to the ordering physician, vendor, and the member. A Clinical Services care manager will inform the requester of the denial.

4.4 Billing for DMEPOS Provided to Members Registered as Inpatients or Outpatients at a Facility

Providers who supply durable medical equipment, orthotics, prosthetics, and supplies (DMEPOS) to Highmark members when they are registered as inpatients or outpatients at a Highmark-contracted facility may bill Highmark for a very limited scope of equipment and supplies.

Billing Guidelines

If a Highmark member is registered as an inpatient or outpatient of a hospital or skilled nursing facility (SNF), DMEPOS providers may bill Highmark for equipment or supplies provided to the member ONLY when one of the following apply:

• The equipment or supplies require approval and authorization by Highmark’s Clinical Services.
• The equipment or supplies are customized specifically for the individual member’s use in the home setting (e.g., customized power wheelchairs, customized splints or braces provided to the member for use in the home).

For any other DMEPOS supplies or equipment furnished to members who are registered as inpatients or outpatients of a facility, it is the responsibility of the Highmark-contracted hospital or SNF to provide the supplies or equipment and to seek payment from Highmark, as appropriate. Other DMEPOS supplies or equipment include, but are not limited to, items such as crutches, walkers, canes, and soft goods.

These requirements apply to all Highmark products, including Medicare Advantage HMO and PPO products.

Exceptions for Medicare Advantage Members Residing in SNFS

These requirements do not apply in the case of DMEPOS items provided to Medicare Advantage HMO or PPO members residing in a SNF who have exhausted their 100-day skilled nursing benefit or are receiving a non-skilled level of care.

Under these circumstances, the billing process should be treated as if the member is living in his or her own residence. Therefore, the DMEPOS provider would bill the claim to Highmark.

4.4 Home Infusion Therapy Guidelines

Home infusion therapy (HIT) is the administration of medically necessary fluids or drugs through a central line or peripheral vein to Highmark members in their homes or places of residence.

Drug therapies commonly administered by infusion include antibiotics, chemotherapy, pain management, and parenteral nutrition.

Here are examples of certain conditions that commonly require infusion therapy:

• Infections that are unresponsive to oral antibiotics
• Cancer and cancer-related pain
• Gastrointestinal diseases or disorders that prevent normal functioning of the gastrointestinal system
• Immune disorders

Home nursing services are also provided to ensure proper patient education and training and to monitor the care of the patient in the home.

Provider Guidelines

Home infusion therapy providers must possess a current pharmacy license from the state in which they provide services. They must also maintain accreditation from one of the following: The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations); Accreditation Commission for Health Care, Inc.; Community Health Accreditation Program, Inc.; The Compliance Team, Inc.; or Healthcare Quality Association on Accreditation.

Provider agrees to submit claims to Highmark for all Highmark members (must use best efforts to submit claims electronically). Providers also agree to accept Highmark’s payment for covered services they perform. The provider will not charge the member for covered services the provider has agreed to provide except for applicable copayment, coinsurance, and deductible amounts.

In Pennsylvania, the provider agrees to provide:

• Dedicated customer service personnel
• A toll-free telephone number
• 24-hour availability for service and delivery
• 24-hour turnaround time to accept patient to service except for customized, specialized, or significantly customer-specific product 

Nursing Services for Home Infusion Therapy

Per diem rates are all-inclusive rates for medically necessary services. They include all ancillary services and supplies (e.g., durable medical equipment or supplies as needed, educational materials, basic solutions, administrative supplies, and the defined nursing hour increment).

Daily maintenance and a flush kit are integral components to the per diem allowance regardless of the mode of access. Since daily maintenance and flush kits were considered in the development of the fee schedule, Highmark will not provide separate payment for these services.

Multiple Infusion Therapies

Multiple infusion therapies apply to patients who require multiple concurrent infusion treatments including, but not limited to, multiple antibiotics, hydration, chemotherapy, and enteral feeding therapy. Highmark will not reimburse separately for each therapy. Instead, the provider must bill and will be reimbursed for the most costly per diem that applies plus the drug(s) administered.

When billing for multiple therapies on the same claim, bill only for the most costly procedure. Do not report zero-dollar charges for the remaining therapies.

Exception: The only exception to this is aerosolized AIDS drug therapy. It is the only therapy that must be billed in conjunction with another mode of home IV therapy administration. It is also the only drug therapy that, while provided as part of a multiple-therapy treatment, can be billed as a separate service. Use procedure code S9061 to report aerosolized AIDS drug therapy.

Billing and Reimbursement for Drugs Administered

Follow these guidelines when reporting drugs administered by home infusion therapy:

• If the patient administers the drugs, and the home infusion provider provides the drugs but no nursing services, bill for the supplies or drugs but not a per diem nursing visit.
• Report the correct procedure code according to the date of service and the effective date of your contract.
• When billing for drugs administered through home therapy infusion, bill the amount of drug based on the smallest available commercial size.
• Drug claims billed under Highmark medical benefits require the submission of National Drug Code (NDC) information. Please see the List of Procedures Requiring NDC Information. This list is also available under Policies and Programs then Pharmacy Programs on the Provider Resource Center.

4.4 Medicare Advantage Guidelines for DMEPOS Upgrades

Generally, upgrades to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are defined as items that go beyond what is medically necessary. An upgrade may be from one Healthcare Common Procedure Coding System (HCPCS) code to another HCPCS code, or it may be from one item to another within the same HCPCS.

The payment for an item must be consistent with what is considered reasonable and medically necessary to serve the intended purpose. In cases where an item is considered to be medically necessary and covered, and a member wishes to obtain an item with upgraded features, payment is based on the allowance for the item normally used for the intended purpose.

Claim Submission and Reimbursement

Highmark requires providers to bill these services as they do for Medicare fee-for-service beneficiaries. The items should be billed as two separate line items, one for the upgraded item and one for the standard item.

If it is determined that the upgrade was not medically necessary, payment is made on the standard item and the line item for the upgraded item will be denied. Liability will be set based on which modifiers were billed on the line.

4.4 Medicare Advantage Home Oxygen Therapy

Conditions for Which Coverage is Available

Home oxygen therapy coverage is available for rented, not purchased, oxygen equipment for members with significant hypoxemia in the chronic stable state provided all of the following conditions are met:

1. The attending or consulting physician has determined that the patient suffers a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy.
2. The patient’s blood gas levels indicate the need for oxygen therapy.
3. Alternative treatment measures have been tried or considered and have been deemed clinically ineffective. 

Conditions for Which Coverage is Not Available

Coverage for oxygen therapy for Medicare Advantage members is not available for the following conditions:

1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood, and there are other preferred treatments.
2. Dyspnea without cor pulmonale or evidence of hypoxemia.
3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.
4. Terminal illnesses that do not affect the respiratory system.

Portable Oxygen Systems

Coverage of a portable oxygen system alone or to complement a stationary oxygen system may be allowed if the patient is mobile within the home. When submitting an authorization request, please check both the “portable” box and the “stationary” box.

Spare Tanks or Emergency Inhalators

Spare tanks of oxygen or emergency oxygen inhalators are considered not medically necessary since these items are precautionary and not therapeutic in nature.

Blood Oxygen Determinations

Initial orders for oxygen therapy must also include the results of a blood gas study, usually a measurement of the partial pressure of oxygen (PO2) in arterial blood. The study must be performed within 30 days before the date of service.

The study should be performed under one of the following circumstances:

• Ordered and evaluated by the attending or consulting physician.
• Ordered and evaluated by the attending physician and performed under his or her supervision.
• Performed by a qualified provider of laboratory services.

Note: Highmark does not consider suppliers as qualified to perform blood gas studies and will not pay for a qualifying blood gas study if performed by a supplier.

Conditions of Blood Gas Studies

The conditions under which the blood gas study was performed must be specified in writing and submitted on the Certificate of Medical Necessity (CMN) form. Examples of this documentation may include: at rest, while sleeping, while exercising, on room air, on oxygen, etc.

Note: If the study is performed while the patient is receiving oxygen, indicate the amount, body position during testing, and any additional information required for interpretation.

Blood Gas Level Criteria

The table below describes three groups of blood gas levels for which coverage is provided. 

Additional Studies

Retesting between the 61^st and 90^th day of home oxygen therapy is required in order to establish continued medical necessity when a patient’s initial certification for oxygen is approved based on one of the following criteria:

• Arterial PO₂ was 56 mm Hg or greater
• Oxygen saturation was 89% or greater

Certificate Of Medical Necessity (CMN)

A Certificate of Medical Necessity (CMN) form for home oxygen is necessary for the following:

• Initial certification
• Recertification
• Changes in the oxygen prescription

The CMN must be completed, signed, and dated by the ordering physician.

Obtaining Authorization

Please review the prior authorization list on the Provider Resource Center for your region to determine which oxygen services require an authorization. If authorization is required, follow the steps listed below:

Recertification

Recertification must include the results of a recently performed arterial blood gas (ABG) or oximetry test; and it is required one to three months after initial certification under the following circumstances:

• If the patient’s arterial PO2 was 56 mm HG or greater at the initial certification.
• If the patient’s oxygen saturation was 89% or greater at the initial certification.
• If the physician initially estimated that oxygen was needed for one to three months.

Note: Once recertification establishes medical necessity for continued therapy, subsequent recertification is not required except when there is a change in the oxygen prescription or the attending physician.

4.4 Diabetic Testing Devices for Medicare Advantage Members

Medicare Advantage HMO and PPO products provide coverage for medically necessary diabetic testing devices including glucometers, test strips, and lancets under the durable medical equipment (DME) benefit. Insulin pens and insulin pumps are also covered under the DME benefit.

Insulin and syringes will not be covered as DME, but will be covered under the Medicare Part D Prescription Drug Benefit.

Purchasing Diabetic Testing Devices

Members are able to purchase diabetic testing devices from any participating, in-network DME vendor with applicable member cost-sharing under Medicare Advantage. Supplies obtained from an in-network DME supplier are covered in full after coinsurance.

Although Medicare Advantage PPO members have out-of-network benefits, those members who elect to go out-of-network to purchase DME supplies will incur additional out-of-pocket expenses. Please review the patient’s specific benefit design to determine possible authorization requirements and/or coinsurance amounts and maximum annual coinsurance amounts.

Prescriptions for Multiple, Daily Diabetic Testing

If a patient is instructed to test multiple times in the same day for diabetes, treatment prescriptions for DME diabetic supplies should be written clearly to state the correct frequency of testing (e.g., “to be tested three times daily”). This will ensure that the correct amount of supplies are ordered and submitted for DME coverage under a Medicare Advantage product.

Many of the in-network DME vendors can supply increased supplies in a timely manner. If a patient requires additional supplies, the treating physician will need to provide the patient with a new prescription detailing the testing frequency. After receiving the new prescription, the patient will need to contact the DME vendor to indicate that their testing needs have increased and that their physician wrote a new prescription detailing the change.

Mail-Order Diabetic Testing Supplies

Members are able to order 90-day supplies of diabetic supplies via mail order. The physician must write the prescription to reflect the long-term supply so that the member is able to submit the prescription to the mail order DME vendor and receive accurate long-term supplies.

For More Information

If you have specific questions about diabetic testing devices for Medicare Advantage members, contact the Provider Service Center.

4.4 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.