5.5 Medical Necessity Denials

5.5 Benefit Denials

5.5 Peer-to-Peer Conversation

5.5 Provider Appeals

5.5 Pre-Payment Coding Dispute Resolution

5.5 Expedited Provider Appeal Process

5.5 Standard Provider Appeal Process

5.5 Filing An Appeal on Behalf of the Member

5.5 Adverse Benefit Determination Appeal: Filing on Behalf of a Member (PA Acts 68 and 146)

5.5 Expedited Adverse Benefit Determination Appeal: Filing on Behalf of a Member (PA Acts 68 and 146)

5.5 Grievances and Appeals (NY Only)

5.5 Pennsylvania CHIP Complaints, Grievances, and External Review

5.5 Expedited Review Process Under the Autism Mandate (PA Act 62)

5.5 Medicare Advantage: Provider Appealing on Own Behalf

5.5 Medicare Advantage: Appeals on Behalf of a Member

5.5 Provider Appeal Rights for Prescription Drug Benefits

5.5 Disclaimers

5.5 Medical Necessity Denials

When a determination is made to not authorize a service, the denial could be either for medical necessity or benefit related. This section includes information on medical necessity denials. Please see the applicable section in this unit for benefit denials.

Medical Necessity Definition

Medical Necessity means health care and services that are necessary to prevent, diagnose, manage, or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap.

We will reimburse for medically appropriate care that is not more costly than alternative services or supplies and is likely to produce equivalent results for the person's condition, disease, illness, or injury.

Physician Reviewer

When a provider requests authorization for an admission or a service, but it is determined that the applicable medical necessity criteria are not met, the case is forwarded to a physician reviewer:

• If the physician reviewer disagrees and determines that the service is in fact medically necessary, an authorization is issued.
• If the physician reviewer agrees with the initial assessment that the service is not medical necessary, a medical necessity denial is issued. Only a physician can render a denial as not medically necessary.

This process applies whether the authorization request was submitted through Availity® or initiated by telephone contact with Clinical Services.

Behavioral Health Review Process

When Highmark Behavioral Health Services makes the initial assessment that a member’s case does not meet the applicable medical necessity criteria, alternative levels of care may be discussed with the requesting provider. If these suggestions are not acceptable to the treating physician or the facility, the behavioral health care manager refers the case to a physician reviewer:

• If the physician reviewer disagrees and determines that the service is in fact medically necessary, an authorization is issued.
• If the physician reviewer’s decision is to not authorize the services, a verbal notice of non-authorization is given to the provider, and a written notice follows within one business day after the verbal notice. 

Written Notification of Denial

Providers are notified verbally, as well as formally by letter, when the decision is made to not authorize a service. Providers also receive denial notifications through Predictal, which can be accessed via Availity.

Content of Denial Letter

As required by regulatory and accrediting agencies, denial letters contain very specific information, including the following:

• Identification of the denied service(s) and service date(s), when applicable
• Clinical rationale that provides a clear and precise reason for the decision
• Utilization criteria, medical policy, or benefit provisions used in making the adverse determination
• A statement that a copy of any policy, criteria, guideline, or other information referenced is available upon request (not applicable to Medicare Advantage)
• Suggested alternative level of care, if appropriate
• Suggested alternatives for treatment if benefits are exhausted
• Information about member and provider appeal rights and the process to initiate an appeal
• A description of appeal rights (standard and expedited appeals) including the right to submit written comments, documents, or other information relevant to the appeal.

Financial Responsibility Agreement

In accordance with Highmark's policy on denials for medical necessity reasons (including clinical appropriateness as to site of service) or any non-covered services, the member cannot be billed unless he or she has specifically agreed in writing, in advance of the service, to be financially responsible for the entire expense. This financial responsibility agreement must specify the procedure to be performed and include an estimate of the cost of the procedure.

Note: The general waiver document routinely signed by patients at admission or registration is not sufficient for this purpose.

5.5 Benefit Denials

Benefit Verification is Provider Responsibility

It is the responsibility of the provider to verify that the member’s benefit plan provides the appropriate benefits before rendering a service. Availity's Eligibility and Benefits Inquiry provides the information needed to make this determination.

If Availity is unavailable, providers can contact the Highmark Provider Service Center for information about benefits for medical services, or Highmark Behavioral Health Services for information about benefits for behavioral health services.

Notification of Denial

When authorization requests are submitted by telephone contact, the care manager can assist the provider by verifying whether the member’s benefit plan provides the specific benefit for the service to be rendered.

If, in fact, the member does not have the benefit, the care manager notifies the provider verbally and follows up with a benefit denial letter.

Member's Right to Appeal

Although the provider is not permitted to appeal a benefit denial, the member can do so. The benefit denial letter addressed to the member provides the information needed to initiate the appeal.

5.5 Peer-to-Peer Conversation

The purpose of the peer-to-peer conversation is to allow the ordering or treating provider an opportunity to discuss a medical necessity denial determination. This process is typically initiated when a peer-to-peer conversation did not occur prior to the initial denial determination.

Peer-to-Peer Option Offered at Time of Denial Notification

Highmark will advise the treating provider of the availability of this process for commercial members when verbally notifying the provider of an authorization denial (if a peer-to-peer conversation has not already occurred). This discussion may help resolve the issue and spare the time and expense of an appeal.

Note: If the provider chooses to proceed with an appeal, the peer-to-peer option is forfeited and no longer available to the provider.

Important

The peer-to-peer conversation option is not available for Medicare Advantage members.

Process

For commercial members, the provider may request a peer-to-peer conversation prior to the start of the appeal and upon receipt of the initial denial determination via verbal, electronic, or written notice.

If the physician who issued the denial is unavailable, another physician reviewer will be available to discuss the case. In the event the peer-to-peer conversation does not result in an authorization, the provider and member will be informed of their appeal rights and procedures.

Initiating A Peer-to-Peer Conversation

To initiate a peer-to-peer conversation, the provider should call the dedicated peer-to-peer toll-free phone number: 866-634-6468. Hours of operation are from 8:30 a.m. to 4:30 p.m. (EST), Monday through Friday.

Providers are encouraged to call during hours of operation to speak with a live intake agent who will gather the necessary information and answer any questions. When speaking with a live intake agent, providers will have the following options:

• Warmline transfer to the first available Highmark Clinical Peer Reviewer to conduct the peer-to-peer conversation.
• Schedule a peer-to-peer conversation with the Highmark clinical peer reviewer who made the determination (or an appropriate designee), at the requesting provider’s convenience.

If an emergent need arises before or after business hours, the option to leave a voicemail message is available. The following information will be needed:

• CASE/REQ# (e.g., REQ-1234)
• Patient’s name and Member ID
• Name of the treating and/or ordering provider requesting the peer-to-peer conversation and the phone number where a Highmark clinical peer reviewer can reach the provider

The Highmark clinical reviewer will contact the provider within one business day from the time of the request.

Outcomes of Peer-to-Peer Conversation

If the peer-to-peer conversation or review of additional information results in an approval, the physician reviewer informs the provider of the approval.

If the conversation does not result in an approval, the physician reviewer informs the provider of the right to initiate an appeal and explains the procedure to do so.

Reconsideration Appeal

If attempts to discuss with the provider an initial adverse determination by the Plan's Medical Director are unsuccessful, the provider may request reconsideration. Except in cases of retrospective reviews, such reconsideration shall take place within one business day of the request. The provider is expected to share information via telephone and fax to provide the reviewer with complete information regarding the case. Once the necessary clinical information is received, reconsideration is conducted by the member's health care provider and clinical peer reviewer.

Highmark Blue Cross Blue Shield (WNY) or Highmark Blue Shield (NENY) may reverse a preauthorized treatment, service, or procedure on retrospective review when:

• Relevant medical information presented upon retrospective review is materially different from the information that was presented during the preauthorization review; and
• The information existed at the time of the preauthorization review but was withheld or not made available; and
• The clinical reviewer was not aware of the existence of the information at the time of the preauthorization review; and
• Had they been aware of the information, the treatment, service, or procedure being requested would not have been authorized.

5.5 Provider Appeals

Highmark follows an established appeals/grievance process as a mechanism for providers to appeal an adverse benefit determination. This section will describe the specific processes as they apply to providers appealing on their own behalf for services provided to Highmark members. Please see the Medicare Advantage: Provider Appealing on Own Behalf section of this unit for Medicare Advantage members.

A provider may appeal a medical necessity denial decision, including decisions to deny experimental/investigational cosmetic procedures, or in certain cases, out-of-network. At the time of a denial determination, the provider is informed of the right to appeal and the process for initiating an appeal.

Note: In Delaware, the provider appeal processes outlined here apply only to providers participating in Highmark Delaware’s provider networks.

Applicable Products

The provider appeal processes described here apply to all Highmark members except those with coverage under Highmark's Medicare Advantage products or products sold on the Marketplace Exchange.

• For the provider appeal processes applicable to Medicare Advantage products, please see content later in this unit.
• For information regarding appeals in Delaware, Pennsylvania, and West Virginia related to Affordable Care Act (ACA) regulated, under 65 on-exchange products, please call the customer service phone number on the back of the member’s identification card.

Initiating an Appeal

Requests for appeals may be submitted either by telephone or in writing.

A provider has 180 days from the date of the initial denial of coverage in which to file an appeal in all of Highmark’s service areas in Delaware, New York, Pennsylvania, and West Virginia (PA CHIP exception below).

Highmark Healthy Kids (CHIP) Filing Time Frame

For the Highmark Healthy Kids/Children’s Health Insurance Program (CHIP) in Pennsylvania, a provider has 60 days from the date of the initial denial of coverage in which to file an appeal. 

Types of Provider Appeals

There are two types of appeals available to the provider following a medical necessity denial – expedited appeal or standard appeal. The type of appeal is determined by the urgency of the situation, as well as the physician’s assessment of the situation.

Explicit directions for filing appeals appear in the written denial notification, which is sent to the member or the member’s representative and the physician and/or facility, as appropriate. This process involves a verbal or written request initiated by the provider to review a determination that denied payment of a health care service for medical necessity. A clinical peer reviewer who was not involved in the original denial must conduct the review.

Expedited Appeal

An expedited appeal is used when a member is receiving an ongoing service or a member is scheduled to receive a service for which coverage has been denied, but the treating provider believes that a delay in service will adversely affect the member’s health. This process may be used when any of the following circumstances exist:

• A delay in decision making might jeopardize the member’s life, health, or ability to regain maximum functions based on a prudent layperson’s judgment and confirmed by the treating practitioner; or
• In the opinion of the practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request; or
• Concerning the admission, continued stay, or other health care services for a member who has received emergency services but has not been discharged from a facility; or
• Concerning a concurrent review; or
• Situations in which a health care provider believes an immediate appeal is warranted, except post-service denials; or
• Denial for home health care services following a discharge from a hospital admission; or
• You are asking for home care services after you leave the hospital (New York only); or
• You are asking for more inpatient substance abuse treatment at least 24 hours before you are discharged (New York only); or
• You are asking for mental health or substance abuse services that may be related to a court appearance (New York only). 

Standard Appeal

A standard appeal is used for preservice denials in non-urgent situations and for appeals of a post-service denial decision, including denials resulting from retrospective reviews of services rendered without the required authorization.

It is also used as a secondary appeal level when a denial is upheld under the expedited appeal process. In West Virginia and Delaware, provider appeal rights are exhausted after the standard appeal.

Highmark’s Appeal Review Process Follows All Applicable Accreditation Requirements

Highmark’s process for reviewing appeals follows all applicable accreditation requirements. These include the following components:

• Review by a clinical peer reviewer who is board certified and holds an unrestricted license and is in the same or similar specialty that typically manages the medical condition, procedure, or treatment under review.
• Reviewer is neither the individual who made the original decision nor the subordinate of such individual.
• Review of the appeal is within time frames established by the applicable regulations and standards.
• Verbal (as applicable) and written communication of the decision is sent within time frames established by the applicable regulations and standards.

Responsibility For Medical Treatment and Decisions

Under all circumstances, the member and the physician bear ultimate responsibility for the medical treatment and the decisions made regarding medical care. Providers and Highmark employees involved in utilization management decisions are not compensated for denying coverage nor are there any financial incentives to encourage denials of coverage.

Out-of-Network Appeals

A member or the member's designee may appeal an out-of-network denial by submitting

1. A written statement from the member's attending physician, who must be a licensed, board certified, or board eligible physician qualified to practice in the specialty area of practice appropriate to treat the member for the health service sought, that the requested out-of-network health service is materially different from the health service the health care plan approved to treat the member's health care needs; and
2. Two documents from the available medical and scientific evidence that the out-of-network health service is likely to be more clinically beneficial to the member than the alternate recommended in-network health service and for which the adverse risk of the requested health service would likely not be substantially increased over the in-network health service. 

Full and Fair Review Process

This is for all lines of business except Medicare Advantage and Administrative Services Only (ASO) that are grandfathered per HR3590H.R. Patient Protection and Affordable Care Act (PPACA).

The purpose is to provide the claimant with all the new or additional evidence that the plan considers, relies upon, or generates in connection with an appeal that was not available when the initial adverse determination was made. The claimant will be provided any and all additional information submitted during their appeal process which resulted in a final adverse determination.

5.5 Pre-Payment Coding Dispute Resolution

The pre-payment coding review dispute resolution process is a second-level appeal process that is intended to address a multitude of pre-payment coding or claim content disputes. Highmark will use this process to resolve any pre-payment coding or claims contents disputes for claims that have already undergone a standard appeal. Providers who initiate a second-level appeal process for pre-payment coding will be bound to the final resolution of the Pre-Payment Dispute Resolution.

Any provider has the right to dispute claims payment decisions related to coding or claim contents made by Highmark. All disputes related to coding or claim contents will be governed by the terms of the provider agreement and not under the member’s benefit plan. Requests for payment of services will be made directly to Highmark rather than the member’s benefit plan. This includes plans governed by either the Employee Retirement Income Security Act of 1974 (ERISA) or the Patient Protection and Affordable Care Act of 2010 (PPACA).

Important

This process is distinct from the post-payment Coding Audit Dispute process which is discussed in further detail in Chapter 6 Unit 8: Payment Review. The post-payment dispute process is only for coding disputes related to post-payment audits.

Pre-Payment Coding Dispute

A pre-payment coding review dispute is a dispute that arises due to one or more claim reviews conducted by Highmark and/or its designated agents. Pre-payment review disputes include, but are not limited to dispute(s) that arise after one or more pre-payment claims coding reviews have been conducted by Highmark and resulted in:

• A disagreement between Highmark and the provider on the appropriate procedure code(s) assigned to the diagnosis and/or service rendered
• A disagreement between Highmark and the provider about a diagnosis code assigned to a claim
• A disagreement between Highmark and the provider about claim contents including but not limited to; revenue codes, place of service, or modifiers
• A resolution not being resolved by the parties through informal means

Appeal Rights

Providers who do not agree with Highmark pre-payment coding review findings must request a first-level appeal in accordance with the instructions provided on the applicable pre-payment review determination letter. This letter may come from Highmark or a designated agent of Highmark. If a denial letter is not received, please contact Highmark via Message this Payer in Availity®.  

If providers are not satisfied with the appeal determination, they may have the right to request a second level appeal to have the dispute reviewed by an independent review organization (IRO). Second level appeal determinations made by the IRO are final and binding on both the provider and Highmark except for providers located in Delaware (see below).

Delaware Department of Insurance

Providers in Delaware who are not satisfied with Highmark’s final appeal decision have a right to request arbitration through the arbitration program administered by the Delaware Department of Insurance, including when the arbitrations involve disputes related to primary care or chronic care management providers reimbursement pursuant to 18 Del. C. §§3342B and 3556A.

Determinations made by the Delaware Department of Insurance are binding on both the provider and Highmark. However, the losing party has a right to trial de novo in the Delaware Superior Court so long as notice of appeal is filed with that Court in the manner set forth by Superior Court rules within 30 days of the date of the arbitration decision being rendered.

Use of an Independent Review Organization

When a provider disputes a pre-payment coding decision made by Highmark or its designated agent, the provider and Highmark shall make a good faith effort to resolve the dispute by first exhausting available appeal options and must discuss the matter with the appropriate representative(s).

Following the exhaustion of available appeal option(s), the provider may request a second-level appeal which results in a review by an Independent Review Organization (IRO) to perform a review and conclusively resolve the dispute. To initiate an external pre-payment coding review by an IRO, the provider must send an email request to the following email address:

• IROAppealRequest@highmark.com

The following must be included in the email:

• Claim number
• Member name
• Date of service
• Reason for dispute
• Supporting documentation/records
• Selection of the IRO for external review:
  • Advanced Medical Reviews (AMR)
  • National Medical Reviews (NMR) 
• Contact name, email address, and phone number

Response will be provided within 30 days from date of request for external review. Once started, this process will be the sole means for resolving pre-payment coding disputes.

Independent Review Organization Fees and Costs

When the IRO’s decision on a second-level pre-payment coding review is fully in favor of one party, the losing party must pay the entire fees and costs associated with the IRO’s review and decision. If the IRO’s decision is partly in favor of each party, the parties will share the cost of the review.

Limitation Time Period

All pre-payment coding disputes not resolved by negotiation as described in this section must be submitted to an IRO for a second-level appeal within the time frame outlined in the provider agreement, or where applicable, federal or state law.

5.5 Expedited Provider Appeal Process

Expedited Appeal Process

This process applies in situations where decisions need to be made in an urgent manner prior to services being rendered or for continued stay decisions following a concurrent review denial. All concurrent service appeals are considered urgent.

Note: The expedited appeal process is not applicable when the service has already been rendered.

How to Initiate

Contact Clinical Services to initiate an expedited appeal. Clinical Services may request additional information to be faxed, if needed.

When to Initiate

Prior to the member’s discharge from the facility or before rendering services, but within the applicable time frame from receipt of the denial notification.

The expedited appeal must be initiated within 180 days from receipt of the denial notification in all of Highmark’s service areas in Delaware, New York, Pennsylvania, and West Virginia.

Note: The time frame is within 60 days of receipt of the denial notification for Highmark Healthy Kids (CHIP).

Decision Time Frame

As expeditiously as the member’s health requires, but not to exceed 72 hours (except in New York where you have two business days or 72 hours, whichever is less) from receipt of the appeal request, a decision is rendered to uphold or reverse the original denial.

Note: For Acts 68 and 146 expedited appeals in Pennsylvania, the decision time frame is not to exceed 48 hours. Please refer to the section later in this unit titled “Expedited Appeal: Filing On Behalf of a Member (PA Acts 68 and 146)” for additional information.

Important

If Highmark requires information necessary to conduct an expedited appeal, Highmark shall immediately notify the member and the member's health care provider by telephone or fax to identify and request the necessary information followed by written notification.

A decision will be rendered no later than two business days or 72 hours, whichever is less, after receipt of appeal request. Immediate notification of the decision will be given by telephone, followed by written notice, which will be sent within 24 hours of the appeal decision, but not to exceed two business days or 72 hours, whichever is less. Failure to comply with time frames for an internal appeal of a utilization review determination is deemed a reversal of the initial determination.

Expedited appeals not resolved to the satisfaction of the appealing party may be re-appealed via the standard appeal process or through the external appeal process. The member is not required to exhaust the standard appeal process to be eligible for an external appeal.

Notification of Decision

The appropriate parties will be notified of the determination by telephone, followed by written notification. Written notification will include, but not be limited to, the following information:

• Reason/clinical rationale for an adverse determination
• Source of the criteria used to make the determination
• Right to file a standard appeal and the procedure to initiate it (except in New York where only group plans have a right to file an appeal)

5.5 Standard Provider Appeal Process

This process applies to preservice denials in non-urgent situations and to appeals of a post-service denial decision, including denials resulting from retrospective reviews of services rendered without the required authorization.

Requests for standard appeals may be submitted either by telephone or in writing.

When to Initiate

A provider must file an appeal within 180 days from receipt of the denial notification in all of Highmark’s service areas in Delaware, New York, Pennsylvania, and West Virginia.

Note: The time frame is within 60 days of receipt of the denial notification for Highmark Healthy Kids (CHIP).

Appeal Process

The following process is followed for standard provider appeals:

1. The provider submits a request to appeal an adverse medical necessity decision either by calling Clinical Services or in writing to the applicable mailing address (indicated below).
2. Additional Information:
   1. Delaware, Pennsylvania, and West Virginia: A Clinical Services care manager will contact the provider if any additional information is needed to conduct the review and the provider sends it to the Clinical Services care manager.
   2. New York: if additional information is needed, the member and member’s provider are to be notified, in writing, within 15 days of receipt of the appeal, to identify and request the necessary information. If only some of the requested information is provided, Highmark will make a second request for the missing information in writing, within five business days of receiving the incomplete information.
3. A clinical peer reviewer who was not involved in the original denial decision reviews the case.
4. The provider is notified of the decision by telephone within 30 calendar days (except in New York where written notice will be given within 15 calendar days) of receipt of the request and all pertinent information. Written notification is sent to the provider and the member. 

To Initiate by Telephone

To initiate a standard provider appeal by phone, contact Clinical Services by calling the applicable telephone number for your service area:

Mailing Addresses

Submit all pertinent information to the applicable address below for Commercial appeals. Please see the Medicare Advantage: Provider Appealing on Own Behalf section of this unit for Medicare Advantage members.

Time Frame Compliance

A decision will be rendered no later than 30 calendar days of receipt of appeal request for pre-service appeals and 60 calendar days of receipt of appeal request for post-service appeals. For Commercial, Indemnity, and Exchange plans, a decision will be rendered no later than 30 calendar days of receipt of appeal request (preservice and post service appeals). Written notice to enrollee, the enrollee's designee, and provider will be sent within two business days of the appeal decision. Highmark maintains files on all appeal requests and decisions.

5.5 Filing an Appeal on Behalf of the Member

Any Highmark member has the right to appeal an adverse determination if they are not satisfied with decisions made by Highmark regarding the coverage of services. There are specific federal and state laws and regulations that guide the member appeal process.

As outlined in this section, Highmark will resolve member appeals in a thorough, appropriate, and timely manner in accordance with the Department of Labor (DOL) Claims Procedure Rule under the Employee Retirement Income Security Act of 1974 (ERISA) and the requirements imposed under the Affordable Care Act (ACA). There are separate sections for member appeals under New York law, Pennsylvania law (Acts 68 and 146), and the Children’s Health Insurance Program for PA (Act 146). Please refer to those sections for content on member appeals for members covered by those products.

The DOL appeal process applies to all group health plans governed by ERISA regardless of whether the group is fully insured or self-funded. Highmark also applies this process to all non-ERISA group accounts.

Definition of a Member Appeal

A member appeal is a request from a member, or member’s authorized representative or a provider (with the member’s written consent), to review an adverse benefit determination.

This includes services related to coverage, such as decisions related to the medical necessity and/or appropriateness of a health care service. This also includes full or partial adverse benefit determinations involving a requested health care service or claim.

This process applies to both pre-service and post-service appeals.

Submitting an Appeal on Behalf of the Member

The appeal may be submitted verbally or in writing and should include supporting documentation. Unless requesting an expedited appeal, the appropriate Designation of a Representative form must be completed to submit an appeal request in writing.

These forms can be found on the Provider Resource Center under Resources and Education then Forms.

If the member appoints a provider as his personal representative, the member may not submit his own appeal concerning the services listed in the Designation form. The member may rescind his/her Designation (must be in writing) at any time during the process. 

Filing Time Frame

The appeal must be filed no later than 180 days after receipt of the original denial notification.

Verbal Requests

To submit an appeal request verbally, please contact Highmark by calling the Member Service telephone number on the back of the member’s ID card.

Written Requests

Written appeal requests for Commercial members can be mailed to the appropriate address below. Please see the Medicare Advantage: Appeals On Behalf of A Member section of this unit for Medicare Advantage members.

Letter Acknowledging Receipt

An acknowledgement letter will be sent to the member or to the provider filing on behalf of the member within five business days (except in New York where the written notification will be sent within 15 business days of filing the appeal) from receipt of the request. The letter will include:

• A description of the appeal process.
• A statement affording the opportunity for the member to submit written comments, documents, or other information relating to the appeal.
• A statement advising that the member, or the member’s representative filing on behalf of the member, may have access to information related to the appeal upon request or may submit additional material to be considered.

Medical Necessity Appeals

Any appeals related to medical necessity issues are reviewed by a licensed provider in the same or similar specialty that typically treats the medical condition, performs the procedure, or provides the treatment of the service being appealed. The health care provider will not have been involved in any previous adverse benefit determination regarding the subject of the appeal or be a subordinate of any individual who was involved in the adverse benefit determination.

Benefit Related Appeals

Appeals regarding benefit denials do not require clinical review. The appeals analyst will determine whether the benefit was applied correctly under the applicable benefit program.

Decision Time Frame

With a Pennsylvania plan, for non-urgent reviews, the member and the provider filing on behalf of the member will be notified of the decision in writing within 30 calendar days from receipt of the request for post-service appeals.

With a West Virginia plan, for non-urgent reviews, the member and the provider filing on behalf of the member will be notified of the decision in writing within 10 business days for pre-service appeals, and within 30 calendar days from receipt of the request for post-service appeals.

In Delaware, the member and the provider filing on behalf of the member will be notified of the decision in writing within 30 calendar days from receipt of the request for preservice appeals, and 30 to 60 calendar days for post-service appeals.

Decision letters will provide information on any additional appeal rights that are available.

Urgent Appeals

A request for an urgent review of a previous adverse benefit determination for medical, pharmaceutical, or behavioral health services on the basis of medical necessity and appropriateness may be filed by a member, member’s authorized representative, or a provider (member written consent is not required; however, physician certification is required).

An urgent request will be considered when any or all of these conditions apply:

• A delay in decision-making might jeopardize the member’s life, health, or ability to regain maximum function, or when supported by a provider with knowledge of the claimant’s medical condition;
• A delay in decision-making will subject the member to severe pain that cannot be managed without the care or treatment that is the subject of the appeal;
• A determination that a service is experimental/investigative and, based on the written certification of the treating provider, would be significantly less effective if not promptly initiated;
• The request concerns admission, continued stay, or other health care services for a member who has received emergency services but has not been discharged from a facility; and/or
• The request is concerning a concurrent review.

Requests from providers may be received either verbally or in a written format. Provider requests will be accepted as expedited requests. If a member submits the request, Highmark requires the provider to submit a Physician Certification for Expedited Review form. The Highmark Member Service Representative will send the form directly to the provider and it should be returned to Highmark immediately.

The appeals analyst will notify the provider and member of the decision by telephone and follow up with a written notification to the member and the provider within 72 hours of receipt of the request. The expedited appeal decision letter will provide any additional appeal rights that are available.

Note: When an urgent appeal is filed, no additional internal appeals are available; this applies even if the member’s benefit plan has a two-level internal standard appeal process.

Additional New York Urgent Appeal Guidance

An urgent request will also be considered when:

• Situations in which a health care provider believes an immediate appeal is warranted, except post service denials; or
• Denial for home health care services following a discharge from a hospital admission. 

If Highmark requires information necessary to conduct an expedited appeal, Highmark shall immediately notify the member and the member's health care provider by telephone or fax to identify and request the necessary information followed by written notification. The clinical peer reviewer will be available within one business day, or sooner.

Expedited appeals not resolved to the satisfaction of the appealing party may be re-appealed via the standard appeal process or through the external appeal process. The member is not required to exhaust the standard appeal process to be eligible for an external appeal.

A decision will be rendered no later than two business days or 72 hours, whichever is less, after receipt of appeal request. Immediate notification of the decision will be given by telephone, followed by written notice, which will be sent within 24 hours of the appeal decision, but not to exceed two business days or 72 hours, whichever is less. Failure to comply with time frames for an internal appeal of a utilization review determination is deemed an adverse determination subject to appeal.

Final Adverse Determination of an Internal Appeal Process

Each final adverse determination of an appeal is sent to the member or their designated representative and provider, and must include the following information:

1. A clear statement describing the basis and the specific, scientific, or clinical rationale for the denial and instructions for requesting the clinical review criteria used.
2. Reference to the evidence or documentation used as a basis for the decision, including whether any internal rule, guideline, protocol, or similar criterion was relied upon in making the determination. In cases involving a denial of services, instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used.
3. The provisions of the policy, contract, or plan on which the determination is based.
4. A clear statement that the notice is the final adverse determination.
5. The health care plan's contact person and his/her telephone number.
6. The member's coverage type.
7. The name and full address of the health care plan's utilization review agent.
8. The utilization review agent's contact person and his/her telephone number (for example the manager responsible for the utilization review agent).
9. A description of the health service that was denied, including, where applicable and available, the name of the facility and/or physician proposed to provide the treatment, and/or the developer/manufacturer of the health care service. 
10. A statement that the member may be eligible for an external appeal and the time frames for requesting the appeal.
11. A statement that the member is entitled to receive, upon request and free of charge:
    1. Reasonable access to and copies of all documents, records, and other information relevant to the claim.
    2. A copy of each internal rule, guideline, protocol or similar criterion that was relied upon in making the determination on appeal.
    3. A list of titles and qualifications (including specialist of individuals participating in the appeal review)
12. The information supplied by the Superintendent of the New York State Department of Financial Services (NYSDFS) describing the external appeal process.
13. A statement that the claimant may have a right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA)
14. That Highmark will maintain files on all appeal requests and decisions made. A member must receive standard appeal rights with the expedited internal appeal decision
15. A clear statement in bold that the enrollee has 45 days from the final adverse determination to request an external appeal and that if he/she chooses a 2^nd level of internal appeal time to file external appeal may expire.
16. An attachment with the standard description of the external appeals process

New York State (NYS) External Appeal

A member has the right to an external appeal of certain coverage determinations made by Highmark or our vendors. An external appeal is a request by a member to the New York State Department of Financial Services (NYSDFS) for an independent review by a third party known as an external review agent. External review agents are certified by New York State and may not have a prohibited affiliation with any health insurer, HMO, medical facility, health care provider, or member associated with an appeal. The determination of the external review agent is binding for both the member and Highmark.

Eligibility for a New York State External Appeal

A member cannot request an external appeal unless we have issued a final adverse determination of an Internal Appeal Process. However, if Highmark disagrees with the admission of a provision or continuation of care by a facility for an enrollee diagnosed with advanced cancer (with no hope of reversal of primary disease and fewer than 60 days to live, as certified by the member's attending health care practitioner), Highmark shall initiate an expedited external appeal. Until a decision is rendered, the admission of, provision of, or continuation of care for the enrollee by the facility shall not be denied and Highmark shall provide continued coverage. If Highmark does not initiate an expedited external appeal, then Highmark shall reimburse that facility for services provided. An expedited external review can occur concurrently with the internal appeals process for urgent care and ongoing treatment. Highmark must include an application for an external appeal in the Final Appeal Determinations (FAD) to the member for all denials. Providers may obtain an application on the NYS Department of Financial Services website.

To be eligible for a NYS external appeal, the final adverse determination must be made on the basis that the service is not medically necessary, or the requested service is experimental or investigational, not materially different (out-of-network service request), training and experience (out-of-network referral request) or treatment of rare disease, as explained below:

1. Medical Necessity

The service or treatment is denied, in whole or in part, on the grounds that the service or treatment is not medically necessary and the service would otherwise be covered under the member's contract.

2. Experimental or Investigational 

• The service or treatment is denied on the basis that it is experimental or investigational; and
• The denial is upheld on appeal or both Highmark and the member have jointly agreed to waive any internal appeal
• The member's attending practitioner has certified that the member has a life-threatening or disabling condition or disease (i) for which standard treatment or services have been ineffectual or would be medically inappropriate, or (ii) for which there does not exist a more beneficial, standard service or treatment that is covered, or (iii) for which there exists a clinical trial; and
• The member's attending practitioner (who must be a licensed, board-certified, or board-eligible physician qualified to practice in the area of practice appropriate to treat the member's life-threatening or disabling condition or disease) must have recommended either (i) a health service or treatment or procedure including a pharmaceutical product within the meaning of PHL 4900(5)(b)(B) that, based on at least two documents from the medical or scientific evidence, is likely to be more beneficial to the member than any covered, standard service or treatment; or (ii) a clinical trial for which the member is eligible. Any physician, certification shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation; and
• The service or treatment would otherwise be covered except for the determination that it is experimental or investigational.

3. Out-of-Network Denials

There are two types of out-of-network denials that are eligible for external appeal:

• Out-of-network service denial. The member's preauthorization request was denied because, while the service is not available in-network, the health plan recommends an alternate in-network service that it believes is not materially different from the out-of-network service.
• Out-of-network referral denial. The member's out-of-network referral request was denied because the health plan has an in-network provider with the appropriate training and experience to meet the particular health care needs of the member.

4. Rare Disease

An enrollee with a life-threatening condition who may require "rare disease treatment" may seek an external review for an adverse determination. Treatments of "rare diseases" would be approved, upon external review, if they contain all of the following;

• A physician certification and evidence presented by the insured or the insured's physician
• The treatment for the rare disease would be "likely to benefit" the enrollee, and
• The benefit of such treatment outweighs the risk of said service or procedure.

Agreeing to a New York State (NYS) External Appeal

New York members can request an external appeal even if the initial appeal process is not completed when:

• They have coverage of a health care service which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, that was denied on appeal, in whole or in part, on the grounds of medical necessity, and
• Highmark has rendered a final adverse determination or
• Both Highmark and the member jointly agree to waive any internal appeal.

Highmark is under no obligation to agree to this request. The Manager of Utilization Management Appeals, in conjunction with the Medical Director, considers all requests for waiving the initial appeal process on an individual basis. If Highmark agrees to waive the internal process, Highmark must provide a written letter with information regarding filing an external appeal to the member within 24 hours of the agreement to waive the Highmark internal appeal process. 

New York State (NYS) External Appeal Procedure

Members or their designees must send an external appeal application to the Department of Financial Services within four months from the date of the final adverse determination OR the waiver of the internal appeal process. Providers appealing a concurrent or retrospective adverse determination on their own behalf must request an external appeal within 60 days of the final adverse determination. If you do not send your application to the Department of Financial Services within the required time frame (with an additional eight days allowed for mailing), you will not be eligible for an external appeal. If a member files an external appeal, the member's claim will be reviewed by an External Appeal Agent whose decision will be binding on Highmark and the member.

Providers have their own right to an external appeal when health care services are denied concurrently or retrospectively and must request an external appeal within 60 days. For provider requested external appeals of concurrent adverse determinations: the provider is responsible for the cost if the external appeal is upheld, and both the provider and the plan are responsible for this cost (evenly divided) if the external appeal is upheld in part (partial overturn).

5.5 Adverse Benefit Determination Appeal: Filing on Behalf of a Member (PA Acts 68 And 146)

The Pennsylvania Quality Health Care Accountability Protection Act (Acts 68 and 146) is legislation enacted to protect the rights of members in fully insured health plans. These acts contain provisions that require health plans to establish procedures for member dissatisfactions, complaints, adverse benefit determinations, and grievances according to the legislative guidelines.

Any Highmark fully insured member has the right to file an adverse benefit determination appeal for a medical necessity issue or a complaint for a benefit issue, as applicable, if they are not satisfied with decisions made by Highmark. Acts 68 and 146 give the provider the option of filing an adverse benefit determination on behalf of the member as long as the provider obtains the member’s written consent. An Act 68 and/or Act 146 appeal can be submitted by or on behalf of a member even in situations in which the member is not financially liable for the services in question.

Definitions

A dissatisfaction is when a member expresses to the health plan, either verbally or in writing, that he or she is not satisfied with some aspect of the health care plan or delivery of health care services. A dissatisfaction that concerns the network, benefits, quality of care, etc. becomes a formal complaint if the member, or the member’s authorized representative, requests a review of the matter.

A dissatisfaction becomes an adverse benefit determination when the member, or the member’s authorized representative, files a written or verbal request for review of adverse benefit determination (ABD).

The Act 146 definition of an Adverse Benefit Determination is:

1. a decision by the Plan that, based upon the information provided and upon application of utilization review, a request for a benefit does not meet the Plan’s requirements for Medical Necessity and Appropriateness, health care setting, level of care or effectiveness or is determined to be Experimental/ Investigative, such that the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit;
2. the denial, reduction, termination, or failure to provide or make payment, in whole or in part, for a benefit based on the Plan’s determination of a person’s eligibility for coverage under this Agreement or noncompliance with an administrative policy; or
3. a rescission of coverage determination by the Plan.

Applicable Products

The Acts 68 and 146 adverse benefit determination process described here applies to Highmark fully insured products in Pennsylvania.

Children’s Health Insurance Program

Although Acts 68 and 146 apply to the Highmark Healthy Kids/Pennsylvania Children’s Health Insurance Program (CHIP) managed care plans, the Commonwealth of Pennsylvania Department of Human Services (DHS) provisions include variations on these processes for CHIP.

Refer to the Pennsylvania CHIP Complaints, Grievances, and External Review section of this unit for details of these processes for CHIP.

Definition of an Adverse Benefit Determination

There are two types of adverse benefit determination (ABD) appeal processes — those for Administrative Denials and those for ABDs subject to external review.

The definition of Administrative Denial is a decision based on prior authorization, coverage or payment based on a lack of eligibility, failure to submit complete information, or other failure to comply with an administrative policy.

ABDs subject to external review are those that involve

i. Medical Necessity and Appropriateness;

ii. Health care setting;

iii. Level of care;

iv. Effectiveness of a Covered Service; or

v. Relates to a Claim regarding the Plan’s compliance with the surprise billing and cost-sharing protections under the federal No Surprises Act.

Member's Written Consent Required

A valid written consent, signed by the member, is required before a provider may proceed with the Acts 68 and 146 adverse benefit determination appeal process. The  appropriate Designation of an Authorized Representative form must be completed in its entirety. This form is available on the Provider Resource Center's Miscellaneous Forms page.

The member may not submit a separate appeal on the same issue without rescinding the consent in writing. The member may rescind consent at any time during the appeal process.

Filing Time Frame and Address

The appeal must be filed no later than 180 days after receipt of the original denial notification.

The appeal may be submitted verbally or in writing with supporting documentation and the completed three-page Designation of an Authorized Representative form. Verbal appeals can be initiated by calling the Member Service telephone number on the back of the Member ID card. Written grievances can be sent to:

Western and Northeastern Regions:

Member Grievance and Appeals Department
Highmark
P.O. Box 2717
Pittsburgh, PA 15230-2717

Central Region:

Attention: Grievance Committee
Highmark Blue Shield
P.O. Box 890174
Camp Hill, PA 17089-0174

The Designation of an Authorized Representative forms are available on the Provider Resource Center's Miscellaneous Forms page. There is a section with Appeals forms.

Billing Restrictions

Once a health care provider assumes responsibility for filing an appeal, the provider may not bill the member or the member’s legal representative for services that are the subject of the appeal until the appeal process has been completed or the member rescinds consent.

Letter to Acknowledge Receipt

An acknowledgement letter will be sent to the member and the provider filing on behalf of the member five business days from receipt of the appeal request.

The acknowledgement letter will include the following information:

• The right to submit additional information to support the appeal.
• 30 days for resolution.
• Confirmation that Highmark considers the matter to be an adverse benefit determination rather than a complaint, and that the member, member’s representative, or provider may question the classification of complaints and adverse benefit determinations by contacting the Pennsylvania Department of Health.
• Description of the adverse benefit determination appeal process.
• Member may appoint a representative to act on his or her behalf at any time during the adverse benefit determination appeal process.
• The member, the member’s representative, or the provider filing on behalf of the member may review information related to the adverse benefit determination upon request and submit additional material to be considered by Highmark.
• A statement advising that the member or the member’s representative may request the assistance of a Highmark employee to assist in preparing the first level appeal.

Adverse Benefit Determination Review Process – Internal Level of Review

A provider in the same or similar specialty that typically treats the medical condition, performs the procedure, or provides the treatment will be assigned to review the documentation. The physician reviewer will be an individual who was not involved in any previous adverse benefit determination regarding the appeal and is not a subordinate of any individual involved. The physician reviewer will decide whether to uphold or overturn the initial determination.

The member and the provider filing on behalf of the member will be notified of the decision in writing within 30 calendar days from receipt of the request. The decision letter will contain:

• A statement of the issue under review;
• The basis for the decision;
• The specific reasons for the decision;
• The scientific and clinical rationale for making the decision applying the terms of the plan to the member’s medical circumstances;
• Specific references to the plan’s provisions on which the decision is based or instructions on how to obtain the specific plan provisions; and
• An explanation of how to file a request for a second-level review of the decision and the time frames for requesting a second-level review.

Requesting an External Review

It is not necessary for written member consent for each level of the appeal process. A request to have an adverse benefit determination eternally reviewed by the Insurance Department must be made within four months from receiving notice of the adverse benefit determination decision at the internal level.

Second-Level Review (Independent External Review)

Independent external review requests must be submitted to the Insurance Department within four months from receipt of the decision letter. Within five business days from Highmark’s notification of the external review request from the Department, a preliminary review will be conducted to determine whether:

• The member is or was covered at the time the health care item or service was requested or, in the case of retrospective review, was covered at the time the service was provided.
• The adverse determination does not relate to the member’s failure to meet the requirements for eligibility under the terms of the plan.
• The member has exhausted the plans internal appeal process, unless the member is not required to exhaust the internal appeal process.
• The service, which is the subject of the denied Claim, is not covered because it does not meet the Plan’s requirements as to Medical Necessity and, Appropriateness, health care setting, level of care or effectiveness of a Covered Service, or because the plan determined the service to be Experimental/Investigative for a particular medical condition;
  • with respect to denials based on the experimental and investigational nature of the service, whether the treating Provider has certified that: (1) standard health care services have not been effective, are not medically appropriate or that no alternative Covered Service is more beneficial than the service that is the subject of the denial; and (2) that the recommended service is likely to be more than available standard health care services, or that scientifically valid studies using accepted protocols demonstrate that the requested service requested is likely to be more beneficial to the Member than any available standard health care services.
• The member/member’s representative has provided all the information and forms required to process an external review.

Within one business day after completion of the preliminary review, Highmark will issue a written notification to the Department. If the request is not complete, the notification will describe the necessary information needed to proceed.

The Department will assign an Independent Review Organization (IRO) who will review all information and make a decision within 45 days after the IRO receives the request. The IRO will provide a written decision to the member, the provider filing on behalf of the member, Highmark, and the Department.

5.5 Expedited Adverse Benefit Determination
Appeal: Filing on Behalf of a Member (PA Acts 68 and 146)

A member may request an expedited review at any stage of the Acts 68/146 adverse benefit determination process if the member’s life, health, or ability to regain maximum function would be placed in jeopardy by delay under the time frames of the standard review process.

As in the standard adverse benefit determination process, the member has 180 days from the notification of an adverse benefit determination to file an expedited appeal. Acts 68/146 also gives the provider the option of filing an expedited appeal on behalf of the member.

Expedited Review

A member may request an expedited external review of the Plan’s decision if the initial decision of the Plan or the denial resulting from the Plan’s Internal Adverse Benefit Determination Process involves:

i. an Urgent Care Claim;

ii. an admission, availability of care, continued stay or service for which the Member received Emergency Care Services but has not been discharged from a facility; or

iii. a determination the service is experimental or investigational and, based on the written certification of the treating provider, would be significantly less effective if not promptly initiated.

An expedited external review may not be provided for retrospective adverse benefit determinations.

The Department requires the provider to submit a Physician Certification for Expedited Review Form for verification that the service requires an expedited review. The form should be returned to the Department immediately.

Expedited appeals will follow the Second-Level review process (see previous section on the standard adverse benefit determination process), with written notification of the decision to the member and provider within 72 hours from receipt of the request.

It is the responsibility of the member, or the provider filing on behalf of the member, to provide information to the Department in an expedited manner to allow the parties to conform to the requirements of the expedited process.

A request for an expedited external review must be submitted to the Insurance Department. Upon receipt of a request for an expedited external review, the Insurance Department shall, within 24 hours, send a copy of the request to the Plan.

The Member may choose to request expedited external review at the same time of filing a request for expedited internal review of an adverse benefit determination. If the IRO determines that an expedited internal review is first required, the IRO must notify the Member within 24 hours. Additionally, the Plan may agree to waive the expedited internal review exhaustion requirement.

Within 24 hours of receipt from the Department of the request for an expedited external review, the Plan shall determine whether the request is timely, complete, and eligible for expedited review.

Within 24 hours following completion of this preliminary review of the expedited external review request, the Plan shall notify the Department and the Member, of its determination. The Plan’s determination that the request is not eligible for expedited external review may be appealed to the Department.

Within 24 hours from receipt of the notification that the request is complete and eligible for expedited external review, the Insurance Department shall assign an Independent Review Organization (IRO) to conduct the external review and notify the Plan of the assignment.

Upon receipt of the notification of IRO assignment, the Plan or its Designated Agent shall transmit documents and information considered in making the adverse benefit determination to the assigned IRO in an expeditious manner. Decisions or conclusions reached during the Plan’s initial determination or the Plan’s Internal Adverse Benefit Determination Process are not binding on the IRO.

The assigned IRO will conduct the review and provide notice of its final external review decision as expeditiously as the Member’s medical condition or circumstances require, but in no event more than 72 hours following receipt by the IRO of the request for expedited external review.

If notice of the decision by the IRO is not provided in writing, the IRO must provide within 48 hours following initial notice of its final external review decision written confirmation of that decision to the Plan, the Member, and the Insurance Department. Written notice of the decision shall provide, among other information, a statement of the principal reasons for the decision including the rationale and standards relied upon by the IRO.

Upon receipt of notice that the Plan’s decision was reversed by the IRO, the Plan shall within 24 hours approve coverage of the service that was the subject of the expedited external review request.

5.5 Grievances and Appeals (NY Only)

If a member encounters any concerns, they can usually be resolved with a call to the Member Services Department.

Unresolved complaints or requests to change contractual determinations that are not regarding medical necessity determinations or experimental/investigational determinations can be reviewed through the grievance and appeal procedures. Adverse medical necessity determinations or experimental/investigational determinations are reviewed through the Utilization Management appeals process.

Our grievance and appeal procedure is designed to ensure a timely review of:

• Our members' concerns regarding our policies and procedures; or
• Any decision that we have made regarding a service that they believe is covered by Highmark or should be provided to them as part of their coverage.

A grievance can be requested for any determination made by Highmark other than a decision that a service is not medically necessary or is experimental or investigational in nature. Examples of concerns that may be reviewed under our grievance and appeal procedure include, but are not limited to, the following:

• denial of a referral to a specialist,
• denial of coverage for a referred service,
• denial because a benefit is not covered according to the terms of the member's contract(s),
• denial of a benefit because it was provided by an ineligible provider or at an ineligible place of service, and
• a determination that they were not a member of Highmark at the time services were rendered.

Traditional Indemnity members and individual market products sold on or off the exchanges have a one level grievance process with the following timeframes for response:

• Urgent cases: 72 hours
• Pre-service: 30 calendar days
• Post-service: 60 calendar days

There is a two-level grievance and appeal process for HMO, POS, EPO, and PPO members, as well as for small group products sold on or off the exchanges.

As always, you may file a grievance at your discretion. Highmark will not take any discriminatory action against you because you have filed a grievance or an appeal. 

Designating a Representative

Members may designate someone to represent them with regard to their grievance or appeal at any level. If a representative is designated, we will communicate with the member and their representative, unless directed otherwise. To appoint a representative, the member must complete, sign, and return the Appointment of Authorized Representative Form. This form can be requested by calling Member Services at 800-544-2583.

In cases involving urgent care, a health care professional with knowledge of their medical condition may act as their authorized representative without the need to complete the Appointment of Authorized Representative Form.

Initiating a Grievance (Level 1)

Any time Highmark denies a referral or determines that a benefit is not covered under the member's contract(s), the member will receive notification of our grievance procedures. A written or oral grievance may be filed up to 180 days after the receipt our original determination. Requests for a grievance should state the name and identification number of the member for whom the benefit or referral was denied. It should also describe the facts and circumstances relating to the case. Oral or written comments, documents, records, or other information relevant to the grievance may be submitted.

A grievance may be initiated by calling our Member Service Department at 800-544-2583. Our Member Services Department hours are 8 a.m. - 7 p.m., Monday through Friday. When our offices are closed, the member may notify us about the grievance by leaving a detailed message with our answering service. We will acknowledge receipt of the oral grievance by telephone within one business day of receipt of the message. You may contact Customer Service for language assistance free of charge or if you have special needs.

Please send all written requests for a grievance to:

Grievance Department

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

PO Box 15068

Albany, NY 12212

We will send a written acknowledgment of receipt of a member's grievance within 15 calendar days. This letter will include the name, address, and telephone number of the department that is handling the grievance. It may be necessary to ask for additional information before we can review the grievance. If this is necessary, we will contact the member. 

A Member Services Representative who was not involved in the initial determination and who is not a subordinate of the initial reviewer, will thoroughly research the case by contacting all appropriate departments and providers. The Member Service Representative will review all relevant documents, records, and other information including any written comments, documents, records, and other information the member or their representative have submitted.

If the issues involved are of a clinical nature, it will be reviewed by a health care provider who was not involved in our initial determination and who has appropriate training and experience in the field of medicine involved in the medical judgment. Clinical matters would be those that require appropriate medical knowledge and experience to make an informed decision. The member will be contacted within the following time frames:

In urgent cases, when a delay would significantly increase the risk to the member's health, a decision will be made and communicated to the member by telephone within 48 hours after receipt of the grievance. The member will also be contacted in writing within two business days of the notice by telephone.

In cases involving requests for referrals or disputes involving contract benefits and all other non-urgent cases, a decision will be made and communicated to the member as follows:

• Pre-Service Claims: In writing within 15 calendar days after receipt of the grievance.
• Post-Service Claims: In writing within 30 calendar days after receipt of the grievance

Our response to our member will include the detailed reasons for our determination, the provisions of the contract, policy, or plan on which the decision was based, a description of any additional information necessary for the member to perfect their claim and why the information is necessary, the clinical rationale in cases requiring a clinical determination, the process to file an appeal, and an appeal form.

Appealing an Upheld Denial (Level II)

If a member remains dissatisfied with the outcome of their grievance, they may file an appeal. A request for an appeal should include any additional information the member feels is necessary. Members have 60 business days from the time they receive the grievance determination to submit an appeal to Highmark. They may submit their request for an urgent appeal verbally or in writing. For a non-urgent appeal, they may submit a written request in the form of a letter or use our appeal form. The member will receive a copy of our appeal form with the original grievance decision. They may submit any written comments, documents, records, or other additional information with their appeal.

We will send written acknowledgment of our receipt of the appeal request within 15 calendar days. This notice will include the name, address, and telephone number of the individual who will respond to the member's appeal.

Non-clinical matters will be reviewed by a panel comprised of representative staff from our Network Services, Member Services, Quality Management, and Utilization Management areas who were not previously involved in your grievance.

If the appeal involves a clinical matter, it will be reviewed by a panel of personnel qualified to review clinical matters. This includes licensed, certified, or registered health care professionals who did not make the initial determination. At least one of the health care professionals reviewing the appeal will be a Clinical Peer Reviewer (a licensed physician or a licensed, certified, or registered health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment).

We will make a decision regarding the appeal and send the member notification within the following periods:

• In urgent cases, a decision will be made and notice provided by telephone within 24 hours after receipt of the Level II grievance appeal followed by written notice within two business days after receipt of the appeal.
• For non-urgent pre-service claims, a written decision will be sent within 15 calendar days from receipt of the appeal.
• For post-service claims, a written decision will be provided within 30 calendar days from receipt of the appeal.

Our notification to the member with regards to their appeal will include the detailed reasons for our determination; the provisions of the contract, policy, or plan on which the decision was based; and the clinical rationale in cases where the determination has a clinical basis.

Member Grievance/Appeal

Upon written request, and free of charge, our members have the right to have access to copies of all documents, records, and other information relevant to their claim and details regarding diagnosis/treatment. Members also have the right to request, in writing, the name of each medical or vocational expert whose advice was obtained in connection with their claim. 

Upon written request, and free of charge, members have the right to an explanation of any scientific or clinical judgment for the determination to deny their claim that applies the terms of their contract, policy, or plan to your medical circumstances.

Upon written request, and free of charge, members have the right to a copy of each rule, guideline, protocol, or similar criteria that was relied upon in making the determination to deny their claim.

Members have a right to file a complaint at any time with the NYS Department of Health at 800-206-8125 or the NYS Department of Financial Services Consumer Service Bureau at 800-342-3736.

For questions about your appeal rights or assistance you can contact the Employer Benefits Security Administration at 866-444-3272 or Community Service Society of New York, Community Health Advocates at 888-614-5400.

Members may have the right to bring a civil action under the Employment Retirement Income Security Act of 1974 (ERISA) §502 (a) if they file an appeal and their request for coverage or benefits is denied following review. Members have this right if their coverage is provided under a group health plan that is subject to ERISA.

Quality of Care Access

As a Highmark member, members have the right to ask us to look into their concern about quality of care or timely access to a provider. We closely track all complaints. If we receive similar complaints from our customers about a provider during a certain time period, we address those issues with the provider. This is our informal process.

We also have a formal process. At a member's request, we will investigate their concern by requesting records or other documentation. Our Medical Director reviews this information. If necessary, our Medical Director will meet with the provider to discuss the concern.

If a member has a concern or problem regarding their ability to see a Highmark provider in a timely fashion or the quality of care they receive, they can contact our Member Services Department at 800-544-2583.

We will send the member a letter that explains the complaint process and gives them a number to call if they wish to file a formal complaint. It also explains the appeal process if the member disagrees with the way our staff handles their concerns. 

Unresolved Disputes

We always recommend that members follow our grievance or utilization review process to remedy any issues concerning their coverage. However, if they are not satisfied with any Highmark decision, members have the right to contact the New York State Department of Financial Services or the New York State Department of Health (DOH).

The addresses and telephone numbers for these agencies are:

New York State Department of Health

Corning Tower

Albany, NY 12237

800-206-8125

New York State Department of Financial Services

One Commerce Plaza

Albany, NY 12257

800-342-3736

5.5 Pennsylvania Chip Complaints, Grievances, and External Review

The Pennsylvania Quality Health Care Accountability Protection Act (Act 68) as updated and amended by Act 146 of 2022, legislation enacted to protect the rights of those enrolled in managed care health plans, applies to Highmark Healthy Kids/Pennsylvania’s Children’s Health Insurance Program (CHIP) managed care plans.

In addition, the Commonwealth of Pennsylvania Department of Human Services (DHS) also provides these protections for CHIP with provisions that require some variations from the processes for our other managed care plans.

At any time during the internal complaint or grievance process, a member may choose to designate an authorized representative to participate in the complaint or grievance process on his/her behalf. The member or the member’s authorized representative shall notify Highmark Choice Company, in writing, of the designation. Highmark Choice Company reserves the right to establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a member. Such procedures as adopted by Highmark Choice Company shall, in the case of an Urgent Care Claim, permit a Professional Provider with knowledge of the member’s medical condition to act as the member’s authorized representative.

For purposes of the complaint and grievance processes, member includes authorized representatives and, in the case of a minor, parents of a member entitled or authorized to act on the member’s behalf.

At any time during the internal complaint or grievance process, at the request of the member, Highmark Choice Company will appoint a person from its Member Service Department to assist the member, at no charge, in preparing the complaint or grievance. The Highmark Choice Company employee made available will not have participated in any previous decisions to deny coverage for the issue in dispute.

At any time during the internal complaint or grievance process, a member may contact the Member Service Department at the toll-free telephone number listed on his/her identification card to inquire about the filing or status of a complaint or grievance.

This section will outline the complaint and grievance processes for Highmark Healthy Kids (CHIP) members.

Complaints

A complaint is a dispute or objection regarding a participating provider or the coverage, operations, or management policies of an MCO which has not been resolved by the MCO and has been filed with the MCO. The term excludes a grievance or an adverse benefit determination.

Internal Complaint Process

Highmark Choice Company maintains a complaint process for the resolution of disputes or objections by a member regarding a network provider or the coverage (including contract exclusions and non-covered benefits), operations or management policies of Highmark Choice Company, and the breach or termination of the Highmark Healthy Kids policy. A complaint does not include a grievance.

Members have the right to have complaints internally reviewed through the process described in this Internal Complaint Process.

When a complaint involves an Urgent Care Claim, a single-level review process is available as provided in the section entitled Expedited Review.

When a complaint involves one of the following, a single-level review process is available and the decision may be appealed using the process outlined in the section entitled Appeal of Compliant:

• A denial because the service or item is not a covered service.
• The failure of Highmark Choice Company to meet the required time frames for providing a service or item in a timely manner.
• The failure Highmark Choice Company to decide a complaint or grievance within the required time frames.
• A denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item was provided by a health care provider not enrolled in PROMISe ID.
• A denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item provided is not a covered service or item for the member.
• A denial of a member’s request to dispute a financial liability.

For all other complaints, members must exhaust the two-level process before seeking further administrative review of a complaint by the Pennsylvania Insurance Department.

Initial Review

The member’s initial complaint shall be directed to the Member Service Department. This complaint, which may be oral or in written form, must be submitted within 60 days from the date of the member’s receipt of the notification of an adverse decision or the occurrence of the issue which is the subject of the complaint.

Upon receipt of the complaint, Highmark Choice Company will provide written confirmation to the member that the request has been received, and that Highmark Choice Company has classified it as a complaint for purposes of internal review. If a member disagrees with Highmark Choice Company’s classification of a request for an internal review, he/she may directly contact the Pennsylvania Insurance Department for consideration and intervention with Highmark Choice Company regarding the classification that has been made.

The member, upon request to Highmark Choice Company, may review all documents, records, and other information relevant to the complaint and shall have the right to submit any written comments, documents, records, information, data, or other material in support of the complaint. The initial level complaint review will be performed by an Initial Review Committee which shall include one or more employees of Highmark Choice Company. The members of the Committee shall not have been involved or be the subordinate of any individual who was involved in any previous decision to deny the member’s complaint.

In rendering a decision on the complaint, the Initial Review Committee will take into account all comments, records and other information submitted by the member without regard to whether such information was previously submitted to or considered by Highmark Choice Company. The Initial Review Committee will afford no deference to any prior adverse decision on the Claim which is the subject of the complaint.

Each complaint will be promptly investigated and a decision rendered within the following time frames:

• When the complaint involves a non-urgent care Pre-service Claim, within a reasonable period of time appropriate to the medical circumstances not to exceed 30 days following receipt of the complaint, unless the time frame for deciding the complaint has been extended by up to 14 days at the request of the member;
• When the complaint involves an Urgent Care Claim, within the period of time provided in the section entitled Expedited Review; or
• When the complaint involves a Post-service Claim, within a reasonable period of time not to exceed 30 days following receipt of the complaint, unless the timeframe for deciding the complaint has been extended by up to 14 days at the request of the Member.

Highmark Choice Company will provide written notification of its decision within five business days of the decision, not to exceed 30 days from Highmark Choice Company’s receipt of the member’s complaint, unless the timeframe for deciding the complaint has been extended by up to 14 days at the request of the member.

In the event that Highmark Choice Company renders an adverse decision on the complaint, the notification shall include, among other items, the specific reason or reasons for the adverse decision, the procedure for either (1) requesting a second-level review where permitted or (2) appealing the decision, and a statement regarding the right of the member to pursue legal action.

Second-Level Review

If the member is dissatisfied with the decision following the initial review of his/her complaint and the decision is not one of the following:

• a denial because the service or item is not a covered service;
• the failure of Highmark Choice Company to meet the required time frames for providing a service or item in a timely manner;
• the failure Highmark Choice Company to decide a complaint or grievance within the required time frames;
• a denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item was provided by a health care provider not enrolled in PROMISe ID;
• a denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item provided is not a covered service or item for the member; or
• a denial of a member’s request to dispute a financial liability,

Then the member may request to have the decision reviewed by a Second Level Review Committee. The request to have the decision reviewed must be submitted in writing (or communicated orally under special circumstances) within 45 days from the date an adverse decision is received and may include any written information from the Member or any party in interest.

The Second-Level Review Committee shall be comprised of three individuals who were not involved or the subordinate of any individual that was previously involved in the matter under review. At least one individual of the Committee will not be an employee of Highmark Choice Company or of any Highmark Choice Company related subsidiary or affiliate. The Committee will hold an informal hearing to consider the member’s complaint.

When arranging the hearing, Highmark Choice Company will notify the member in writing of the hearing procedures and rights at such hearing, including the right of the member to be present at the review. If a member cannot appear in person at the second level review, Highmark Choice Company shall provide the member the opportunity to communicate with the Committee by telephone or other appropriate means.

The hearing will be held and a decision rendered within 30 days of Highmark Choice Company’s receipt of the member’s request for review. This applies to both the second-level review of a non-urgent care Pre-service Claim complaint and the second-level review of a Post-Service Claim complaint.

Highmark Choice Company will provide written notification of its decision within five business days of the decision, not to exceed 45 days from Highmark Choice Company’s receipt of the member’s request for review. In the event that Highmark Choice Company renders an adverse decision, the notification shall include, among other items, the specific reason or reasons for the adverse decision, the procedure for appealing the decision and a statement regarding the right of the member to pursue legal action.

Appeal of Complaint to Pennsylvania Insurance Department

If a member is dissatisfied with one of the following complaint decisions,

• a denial because the service or item is not a covered service;
• the failure of Highmark Choice Company to meet the required time frames for providing a service or item in a timely manner;
• the failure Highmark Choice Company to decide a complaint or grievance within the required time frames;
• a denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item was provided by a health care provider not enrolled in PROMISe ID;
• a denial of payment by Highmark Choice Company after the service or item has been delivered because the service or item provided is not a covered service or item for the member; or
• a denial of a member’s request to dispute a financial liability,

The member will have 15 days from the receipt of the notice of the decision to appeal the decision to the Pennsylvania Insurance Department, as appropriate depending on the nature of the dispute. The appeal shall be in writing unless the Member requests to file the appeal in an alternative format.

Appeals to Highmark may be filed at the following address:

Delivery Code: APPEALS
Member Appeals and Grievances
Highmark
120 Fifth Avenue
Pittsburgh, PA 15222

If a member is dissatisfied with a decision of the Second-Level Review Committee, a member will have 15 days from the receipt of the notice of the decision of the Second-Level Review Committee to appeal the decision to the Pennsylvania Insurance Department, as appropriate depending on the nature of the dispute. The appeal shall be in writing unless the Member requests to file the appeal in an alternative format.

Appeals may be filed at the following address:

Delivery Code: APPEALS
Member Appeals and Grievances
Highmark
120 Fifth Avenue
Pittsburgh, PA 15222

All records from the initial review and/or the second-level review shall be forwarded to the Pennsylvania Insurance Department, as appropriate. Additional material related to the complaint may be submitted by the member, the health care provider or Highmark Choice Company. Each shall provide to the other, copies of additional documents provided. The Member may be represented by an attorney or other individual before the appropriate Department.

Grievances

A grievance is a request to Highmark by a member or a member’s authorized representative to have Highmark reconsider a decision solely concerning the medical necessity, appropriateness, health care setting, level of care, or effectiveness of a health care service. If Highmark is unable to resolve the matter, grievance may be filed regarding the decision that:

1. disapproves full or partial payment for a requested health care service.
2. approves the provision of a requested health care service for a lesser scope or duration than requested; or
3. disapproves payment for the provision of a requested health care service but approves payment for the provision of an alternative health care service.

Internal Grievance Process

Highmark Choice Company maintains an internal grievance process by which a member, authorized representative, or a health care provider, with the written consent of the member, shall be able to file a grievance regarding the denial of payment for a health care service on the basis of Medical Necessity and Appropriateness, health care setting, level of care, or effectiveness of a health care service.

Any member or authorized representative who consents to the filing of a grievance by a health care provider may not file a separate grievance. This consent may be rescinded by the member or authorized representative at any time during the grievance process. In the event that the health care provider fails to file or pursue a grievance, the consent shall be deemed as having been automatically rescinded without further action on the part of the member.

A grievance may be filed regarding a decision that: (a) disapproves full or partial payment for a requested health care service; (b) approves the provision of a requested health care service for a lesser scope or duration than requested; or (c) disapproves payment for the provision of a requested health care service but approves payment for the provision of an alternative health care service. A grievance does not include a complaint.

When a grievance involves an Urgent Care Claim, a single level review process is available as provided in the section entitled Expedited Review.

Members must exhaust this internal process before seeking further administrative review of a grievance by the Pennsylvania Insurance Department.

The member’s grievance shall be directed to the Member Service Department. This grievance, which may be oral or in written form, must be submitted within 60 days from the date of the member’s receipt of the notification of an adverse decision or occurrence of the issue which is the subject of the grievance.

Upon receipt of the grievance, Highmark Choice Company will provide written confirmation to the member and the health care provider that the request has been received, and that Highmark Choice Company has classified it as a grievance for purposes of internal review. If a member disagrees with Highmark Choice Company’s classification of a request for an internal review, he/she may directly contact the Pennsylvania Insurance Department for consideration and intervention with Highmark Choice Company regarding the classification that has been made.

The member or health care provider, upon request to Highmark Choice Company, may review documents, records, and other information relevant to the grievance and shall have the right to submit any written comments, documents, records, information, data, or other material in support of the grievance.

The grievance review will be performed by an Initial Review Committee which shall include three or more individuals selected by Highmark Choice Company. The members of the Committee shall not have been involved or be the subordinate of any individual that was involved in any previous decision relating to the member’s grievance. The member or the health care provider may specify the remedy or corrective action being sought. The initial review will include a licensed physician or, where appropriate, an approved licensed psychologist or licensed dentist in the same or similar specialty that typically manages or consults on the health care service at issue.

In rendering a decision on the grievance, the Initial Review Committee will take into account all comments, records, and other information submitted by the member without regard to whether such information was previously submitted to or considered by Highmark Choice Company. The Initial Review Committee will afford no deference to any prior adverse decision on the Claim which is the subject of the grievance.

Each grievance will be promptly evaluated and a decision rendered within the following time frames:

• When the grievance involves a non-urgent care Pre-service Claim, within a reasonable period of time appropriate to the medical circumstances not to exceed 30 days following receipt of the grievance, unless the timeframe for deciding the grievance has been extended by up to 14 days at the request of the member or member's authorized representative;
• When the grievance involves an Urgent Care Claim, within the period of time provided in the section entitled Expedited Review; or
• When the grievance involves a Post-Service Claim, within a reasonable period of time not to exceed 30 days following receipt of the grievance, unless the timeframe for deciding the grievance has been extended by up to 14 days at the request of the member or member's authorized representative.

Highmark Choice Company will provide written notification of its decision within five business days of the decision, not to exceed 30 days from Highmark Choice Company’s receipt of the member’s grievance, unless the timeframe for deciding the grievance has been extended by up to 14 days at the request of the member or member's authorized representative.

In the event that Highmark Choice Company renders an adverse decision on the grievance, the notification shall include, among other items, the specific reason or reasons for the adverse decision including clinical rationale, the procedure for filing a request for external review and a statement regarding the right of the member to pursue legal action.

External Grievance Process

A member, a member’s authorized representative or a health care provider, with the written consent of the member or the member’s authorized representative, may within 15 days from the receipt of the notification of the decision, appeal the denial resulting from the Internal Grievance Process. This can be done by filing a request for an external grievance with Highmark Choice Company. The member should include any material justification and all reasonably necessary supporting information as part of the external grievance filing.

Within five business days of the filing of the external grievance, Highmark Choice Company will notify the Pennsylvania Insurance Department, the member, the authorized representative, or the health care provider, as appropriate, that an external grievance has been filed.

Within two business days of receiving the request, the Pennsylvania Department of Insurance shall randomly assign an IRO on a rotational basis from the designated list and will notify the assigned IRO and Highmark Choice Company of the assignment. Within that same two-day timeframe, the Pennsylvania Insurance Department must also notify the member or the member’s authorized representative of the name, address, e-mail address, fax number, and telephone number of the IRO assigned under this subsection.

The notice will advise the member and the authorized representative of the right to submit additional written information to the IRO within 20 days of the date the IRO assignment notice was mailed and will include instructions for submitting additional information to the IRO by mail, fax, and electronically. If the Pennsylvania Department of Insurance fails to select an IRO within the required time frame, Highmark Choice Company will designate and notify a certified IRO to conduct the external grievance.

Highmark Choice Company shall forward copies of all written documentation regarding the denial, including the decision, all reasonably necessary supporting information, a summary of applicable issues, and the basis and clinical rationale for the decision to the IRO conducting the external grievance within 15 days of the receipt of notice that the external grievance was filed.

Within this same period, Highmark Choice Company shall provide the member or the health care provider with a list of documents forwarded to the IRO for the external review. The member, the member’s authorized representative or the health care provider may supply additional written information, with copies to Highmark Choice Company, to the IRO for consideration on the external review within 20 days of the date of the notice of the IRO assignment was mailed to the member, a member’s authorized representative, or health care provider.

The IRO conducting the external grievance shall review all the information considered in reaching any prior decisions to deny payment for the health care service and any other written submission by the member, the authorized representative, or the health care provider.

Within 60 days of the filing of the external grievance, the IRO conducting the external grievance shall issue a written notification of the decision to Highmark Choice Company, the member, the member’s authorized representative if the representative requested the external review, and the health care provider, including the basis and clinical rationale for the decision.

The external grievance decision may be appealed to a court of competent jurisdiction within 60 days of receipt of the notification of the external grievance decision.

Highmark Choice Company shall authorize any health care Service or pay a Claim determined to be Medically Necessary and Appropriate based on the decision of the IRO regardless of whether an appeal to a court of competent jurisdiction has been filed.

Expedited Review Process

In those cases involving an Urgent Care Claim, there is a procedure for expedited review. In order to obtain an expedited review, the member shall identify the particular need for an expedited review to the Member Service Department. A member shall provide Highmark Choice Company with a certification, in writing, from the member’s physician that the member’s life, health or ability to regain maximum function would be placed in jeopardy or in the opinion of a physician with knowledge of the member’s medical condition would subject the member to severe pain that cannot be adequately managed without the service requested as a result of the delay occasioned by the review process. The certification shall include clinical rationale and facts to support the physician’s opinion. Highmark Choice Company shall accept the physician’s certification and provide an expedited review.

Highmark Choice Company shall conduct an expedited internal review and notify the member, the authorized representative, and the health care provider of its decision as soon as possible taking into account the medical exigencies involved but not later than 48 hours following the receipt of the member’s request for an expedited review. The notification to the member, the authorized representative, and health care provider shall include, among other items, the specific reason or reasons for the adverse decision including any clinical rationale, the procedure for obtaining an expedited external review and a statement regarding the right of the member to pursue legal action.

The member has two business days from the receipt of the expedited internal review decision to contact Highmark Choice Company to request an expedited external review. Within 24 hours of receipt of the member’s request for an expedited external review, Highmark Choice Company shall submit a request for an expedited external review to the Pennsylvania Insurance Department. The Pennsylvania Insurance Department will assign a CRE within one business day of receiving the request for an expedited review. The CRE shall have two business days to issue a decision.

5.5 Expedited Review Process Under the Autism Mandate (PA Act 62)

Overview of Autism Mandate

Pennsylvania Act 62 requires private insurers to provide coverage for medically necessary diagnostic assessment and treatment of autism spectrum disorders (ASD) to covered individuals under 21 years of age.

This mandate applies to any fully insured health insurance policy offered, issued, or renewed on or after July 1, 2009, to groups of 51 or more employees. The mandate also applies to any contract executed on or after July 1, 2009, by the Highmark Healthy Kids/Children’s Health Insurance Program (CHIP).

Expedited Internal Review Process

If the Act 62 ASD mandate is applicable, a covered individual or an authorized representative is entitled to an expedited internal review process upon denial or partial denial of a claim for diagnostic assessment or treatment of ASD, followed by an expedited independent external review process established and administered by the Pennsylvania Insurance Department. A member or authorized representative also has the option to choose the standard appeal process.

The request for an expedited internal review may be submitted verbally or in writing. The mandated expedited review process applies to both pre-service and post-service denials for diagnostic assessment or treatment of ASD.

The expedited internal appeal will be reviewed by the Second Level Review Committee as set forth under Article XXI (Act 68 as amended by Act 146). The Second Level Review Committee is made up of three or more individuals who did not previously participate in the decision to deny coverage or payment for health care services. The committee shall include a licensed physician or an approved licensed psychologist in the same or similar specialty as that which would typically manage or consult on the health care service in question. The members of the review committee shall have the duty to be impartial in their review and decision.

Verbal and written notification of the decision will be issued to you and the member within 48 hours from receipt of the request. The written decision to the member, member’s representative, or provider on behalf of the member will state the basis for the decision, including any clinical rationale, and the procedure for obtaining an expedited external review.

The member, member’s representative, or provider on behalf of the member has two business days from receipt of the expedited grievance decision to request an expedited external review.

Expedited External Review

If an adverse determination is upheld by the internal review committee, the covered individual or an authorized representative is then entitled to an expedited external independent review process administered by the Pennsylvania Insurance Department.

An insurer or covered individual or an authorized representative may appeal an order of an expedited independent external review to a court of competent jurisdiction.

Verify Coverage

To determine if a member is covered under the autism mandate, you can verify the member’s coverage using Eligibility and Benefits Inquiry in Availity® or by calling the Provider Service Center.

5.5 Medicare Advantage: Provider Appealing on Own Behalf

Providers are entitled to appeal a medical necessity denial decision and are informed of this right at the time of the denial decision. Each appeal is processed in a manner consistent with the clinical urgency of the situation.

The processes as described here apply to members with coverage under one of Highmark’s Medicare Advantage products.

When the Provider Can Appeal on His or Her Own Behalf

A provider can make use of this provider appeal process when all of the following are true:

• The provider is contracted with Highmark, and
• The member has coverage under a Medicare Advantage product, and
• The services in question have a medical necessity denial determination, including denials for services considered experimental/investigational or cosmetic in nature, and
• The member is held financially harmless, and
• The provider seeks a resolution in order to obtain payment for the services.

Types of Appeals

Expedited appeals and standard appeals are available to the provider for medical necessity denial determinations.

An expedited appeal is a formal review of an initial adverse medical necessity determination. It can be requested when a delay in decision-making may seriously jeopardize the member’s life, health, or ability to regain maximum function. Highmark reserves the right to determine whether the request meets the criteria for an expedited appeal.

A standard appeal is a formal review of the initial adverse medical necessity determination in which the conditions for expedited appeal are not met. Standard appeal can also be used as a secondary appeal level when a denial has been upheld under the expedited appeal process.

Member Expedited Review Rights

The Centers for Medicare and Medicaid Services (CMS) requires all Medicare Advantage programs to implement processes for member-initiated expedited review of initial determinations and appeals. Members of all Highmark Medicare Advantage programs, or their representatives, may request a 72-hour expedited review of a service if they believe the member’s health, life, or ability to regain maximum function may be jeopardized by waiting for the standard review process. In accordance with CMS guidelines, members may request the initial expedited review without speaking to the PCP first. 

Although these processes are largely member-driven, the provider may represent the member and initiate the expedited review. Highmark reserves the right to determine whether the request meets the criteria for an expedited provider appeal. Each appeal is processed in a manner consistent with the clinical urgency of the situation.

The provider must indicate either verbally or in writing that applying the standard time for making a determination could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function. The provider need not be appointed as the member’s authorized representative to make the request.

Requests For Medical Records

Providers may be contacted by a Highmark staff member or physician reviewer to request a copy of the member’s medical records in the case of an expedited review. If so, you must request the records immediately.

Additionally, if you are contacted for information by a physician reviewer about an expedited appeal, you must return his or her call by 8 a.m. the next day. Failure to do so could result in corrective action and/or sanctioning.

Expedited Appeal Process

This provider appeal process would apply in situations when a decision needs to be made in an urgent manner for a member with Highmark Medicare Advantage coverage. This includes appeals of initial denial determinations prior to services being rendered and appeals of denial decisions for continued services following a concurrent review.

The table below explains the process for expedited reviews of initial determinations or appeals for Medicare Advantage members:

Expedited Appeals

How to Initiate

Requests for expedited review can be initiated either verbally or in writing.

Call the Medicare Advantage Expedited Review Department at

800-485-9610;

or

Fax the information to 800-894-7947;

or

 Submit all pertinent medical and other information to:

Medicare Advantage

Expedited Review Department

P.O. Box 534047

Pittsburgh, PA 15253-5073

When to Initiate

Prior to rendering services, continuing services, or prior to the member’s discharge from the facility; but within 65 days from receipt of the denial notification.

Decision Time Frame

As expeditiously as the member’s health requires, but not to exceed 72 hours from receipt of the appeal request. The 72-hour time frame may be extended by up to 14 calendar days if the member requests or if additional information is needed.

Standard Appeal Process for In-Network Providers

This provider appeal process applies to initial denial determinations for services that have already been rendered, including denials resulting from retrospective review of services rendered without the required authorization.

This process would also apply to appeals for initial preservice denial determinations in non-urgent situations and as a secondary appeal level when an initial denial has been upheld in the expedited appeal process.

The table below explains how the standard review process for Medicare Advantage members works:

Standard Appeals

How to Initiate

Call the applicable Provider Service Center number:

or

Submit all pertinent medical and other information to:

Highmark Medical Review

P.O. Box 890392

Camp Hill, PA 17089-0392

When to Initiate

Within 180 days from receipt of the denial notification.

Decision Time Frame

Within 30 calendar days from the receipt of the appeal request.

5.5 Medicare Advantage: Appeals on Behalf of a Member

Members of a Medicare Advantage plan have a right to file an appeal if their plan will not pay for, does not allow, or stops or reduces a course of treatment that they believe should be covered or provided.

Ordinarily, it is the member or the member’s family who files an appeal if a requested medical service is not authorized; however, the member might ask a provider or other representative to file an appeal on his or her behalf. A provider can do so only if the member would be financially liable for the services.

Representative Statement

The Centers for Medicare and Medicaid Services (CMS) provides an Appointment of Representative (AOR) form (#CMS 1696). 

Members are not required to use the CMS form. They may write their own representative statement appointing a provider or other individual as an authorized representative. The written authorization must contain the following criteria:

• Name, address, and telephone numbers of the enrollee and the individual being appointed
• Enrollee’s HICN or Medicare Beneficiary Identifier, or plan ID number
• The appointed representative’s professional status or relationship to the party
• A written explanation of the purpose and scope of the representation
• A statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative
• A statement by the individual being appointed that he or she accepts the appointment 
• A statement by the individual being appointed that he or she accepts the appointment and the statement is signed and dated by the enrollee and the individual being appointed.

EXCEPTION: In preservice denial situations that meet the criteria for an expedited request, the member’s ordering provider (either contracting or non-contracting) can act as the member’s representative without a signed representative statement.

Types of Appeals

Two types of appeals are available to the member or to the facility acting as the member’s appointed representative:

• Expedited appeal
• Standard appeal 

Expedited Appeals

If the member or the member’s authorized representative believes that following the standard appeal process would seriously jeopardize the member’s life, health, or ability to regain maximum function, an expedited appeal can be requested. The health plan reserves the right to determine whether the request meets the criteria for an expedited appeal.

Highmark will make a decision on an expedited appeal as expeditiously as the member’s health requires, but no later than 72 hours from receipt of the request.

Standard Appeals

Standard member appeals, including those filed on the member’s behalf by a facility, are those that do not meet the criteria for an expedited appeal as determined by the health plan, or those in which the member’s health would not be jeopardized by the standard appeal time frame.

Standard appeals are processed as expeditiously as the member’s health requires, but no later than 30 calendar days from receipt of the request.

Option for Inpatient Discharge Decisions

When an inpatient in a hospital, a Medicare Advantage member has another appeal option if he or she disagrees with a discharge decision. An immediate review by the Quality Improvement Organization (QIO) can be requested.

Note: For more information on this QIO appeal process, see Chapter 5 Unit 3: Medicare Advantage.

Non-Participating Providers

A non-participating provider can file a standard appeal on behalf of a Medicare Advantage member for post-service denials only if he or she submits a Waiver of Liability statement with the appeal. The waiver states that the provider will not bill the member regardless of the outcome of the appeal.

Providers who do not participate with Highmark's Medicare Advantage products should follow the standard appeals process as outlined below when appealing a post-service denial.

Appeal Processes

The table below explains the expedited and standard appeal processes for Medicare Advantage. 

14-Day Extension

The health plan or the facility filing on behalf of the member may request extensions of up to 14 calendar days for rendering a decision.

Requests for extension must be in the best interest of the member. The health plan must justify the need for the extension and notify the member in writing.

If a Denial on an Appeal is Upheld

When the health plan renders an adverse decision on an appeal, Highmark automatically forwards the case to the CMS independent review agency and verbally notifies the member for Medicare Advantage (Part C). 

Note: CMS will provide written notification of its decision to the member. 

Note: For Part D prescription drug coverage, the member or provider must request an appeal through the CMS appeals contractor. The appeals contractor may request additional information. In such cases, a Highmark Medicare Advantage appeals staff member may contact you for additional information. If you are contacted, please respond to the request immediately.

If the CMS independent review agency also renders an adverse decision, the member has the right to initiate further action. The denial communication from the independent review agency includes information about this option.

5.5 Provider Appeal Rights for Prescription Drug Benefits

If you are a participating provider with Highmark and you (or, in New York, the member/the member’s designated representative) disagree with the decision to deny authorization or payment of a prescription drug for a Highmark Commercial member, you have a right to appeal that decision.

Note: This section does not apply to Medicare Part D prescription drug coverage.

Expedited Appeals

Expedited appeals are available when the application of the standard appeal time frame could seriously jeopardize the member’s life, health, or ability to regain maximum function, or would subject the member to severe pain that cannot be managed without the care or treatment which is the focus of the appeal.

To request an expedited appeal, please contact Highmark’s Prescription Drug Department by fax at 866-240-8123; or by calling 800-600-2227.

You will be permitted to provide additional information over the telephone, by fax, or by other appropriate means. A decision will be rendered within two business days of receipt of your appeal request.

Expedited Appeals

Written acknowledgment of receipt of the appeal will be sent to the appealing party upon receipt of the expedited request.

If additional information is necessary to conduct the appeal, the member and the member's health care provider will be notified, in writing, upon receipt of the appeal, to identify and request the necessary information.

The clinical peer reviewer will be available within one business day, or sooner. Appeals will be conducted by a clinical peer reviewer other than the reviewer who rendered the initial adverse determination.

A decision will be rendered no later than two business days or 72 hours, whichever is less, after receipt of the appeal request. Immediate notification of the decision will be given by telephone, followed by written notice, which will be sent within 24 hours of the appeal decision, but not to exceed two business days or 72 hours whichever is less.

Failure to comply with the time frames for an internal appeal is deemed a reversal of the initial determination (except in New York where it is deemed an adverse determination subject to appeal).

Standard Appeals

If you are not eligible for an expedited appeal or your expedited appeal resulted in an adverse determination, you may initiate a standard appeal (New York may also have the right to initiate an external appeal process).

To request a standard appeal, please contact the Highmark Prescription Drug Department by fax at 866-240-8123; or by calling 800-600-2227.

You will be permitted to provide additional information over the telephone, by fax, or by other appropriate means. A decision will be rendered within 30 days of receipt of your appeal request.

New York:

Written acknowledgment of receipt of the appeal will be sent to the appealing party within 15 days of receipt. If additional information is necessary to conduct the appeal, the member and the member's health care provider will be notified, in writing, within 15 days of the appeal, to identify and request the necessary information.

If only some of the requested information is provided, Highmark will make a second request for the missing information in writing, within 5 business days of receiving the incomplete information.

Appeals will be conducted by a clinical peer reviewer other than the reviewer who rendered the initial adverse determination.

A decision will be rendered no later than 30 calendar days of receipt of the appeal request. Written notice to the enrollee, the enrollee's designee, and provider will be sent within two business days of the appeal decision.

Mailing Appeal Requests

Appeal requests can also be mailed to:

Appeals on Behalf of a Member

Providers can initiate appeals on behalf of the member with the member’s written consent (except in New York where written consent from the member is not required). However, if the member gives the provider consent to file an appeal on his or her behalf, then the member is not permitted to file a separate appeal. Member appeal requests must be received within 180 of member receipt of denial.

When submitting appeal requests on behalf of a member, you will be asked to provide the following information:

• The member’s name, the patient’s name, and the group policy number
• The actual drug for which payment was denied and the date of service
• The reasons why you feel the drug should be provided
• Any available clinical information to support your appeal
• Signed consent of member (patient) and provider

Additional information related to member appeal rights will be provided when an appeal request is received.

Final Adverse Determination of an Internal Appeal

Each final adverse determination of an appeal is sent to the member or their designated representative and provider, and must include the following information:

1. A clear statement describing the basis and the specific, scientific, or clinical rationale for the denial and instructions for requesting the clinical review criteria used.
2. Reference to the evidence or documentation used as a basis for the decision, including whether any internal rule, guideline, protocol, or similar criterion was relied upon in making the determination. In cases involving a denial of services, instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used.
3. The provisions of the policy, contract, or plan on which the determination is based.
4. A clear statement that the notice is the final adverse determination.
5. The health care plan's contact person and his/her telephone number.
6. The member's coverage type.
7. The name and full address of the health care plan's utilization review agent.
8. The utilization review agent's contact person and his/her telephone number.
9. A description of the health service that was denied, including, where applicable and available, the name of the facility and/or physician proposed to provide the treatment, and/or the developer/manufacturer of the health care service.
10. A statement that the member may be eligible for an external appeal and the time frames for requesting the appeal.
11. A statement that the member is entitled to receive, upon request and free of charge:
    • Reasonable access to and copies of all documents, records, and other information relevant to the claim.
    • A copy of each internal rule, guideline, protocol, or similar criterion that was relied upon in making the determination on appeal.
    • A list of titles and qualifications (including specialist of individuals participating in the appeal review)
12. A clear statement in bold that enrollee has 45 days from the final adverse determination to request an external appeal and choosing second-level of internal appeal may cause time to file external appeal to expire.
13. An attachment with the standard description of the external appeals process.

Questions?

If you have questions about your right to appeal, or about how to file an appeal, please call the Prescription Drug Department:

• Delaware, Pennsylvania, and West Virginia Prescription Drug Department can be contacted at 800-600-2227 between 8:30 a.m. and 4:30 p.m., Monday through Friday.
• New York Prescription Drug Department can be contacted at 877-698-0793 between 8:30 a.m. and 4:30 p.m., Monday through Friday.

5.5 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Care Benefits Inc., or Highmark Senior Health Company.  Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield. 

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.

5.6 Quality Management Program Overview

5.6 Highmark Quality Program Committees

5.6 Functional Areas and Their Responsibilities

5.6 Case Review Process for Quality Concerns

5.6 Corrective Action and Sanctioning

5.6 Clinical Quality

5.6 Service Quality

5.6 Highmark Quality Initiatives

5.6 Peer Review Protections

5.6 Disclaimers

5.6 Quality Management Program Overview

The Highmark Quality Management Program is designed to ensure that members receive the best quality health care, in the most appropriate setting, in the most cost-effective manner.

Quality Management follows a Continuous Quality Improvement Process model for the ongoing monitoring and analysis of relevant clinical and service quality measures. The model focuses on the early identification of problems, with the development and implementation of interventions that focus on any issues that are identified. The member is at the heart of all activities.

The purpose of the Quality Management Program is to provide the framework and the formal processes within which the organization continually assesses and improves the quality of clinical care, safety, and service to members.

Definitions

Quality improvement processes are those activities that the health plan undertakes to improve the quality and safety of clinical care (including behavioral health care) and the quality of service to members.

Quality management is the integrative process that links knowledge, structure, and processes together throughout the organization to assess and improve quality.

Highmark Quality Management

Highmark's Health Plan Clinical Quality area, part of the Health Plan Chief Medical Officer (CMO) Organization division of Highmark, is responsible for corporation-wide coordination of clinical and service-related improvement initiatives focused on clinical care, member satisfaction, access and availability, and performance measures and outcomes for both physicians and facilities.

Quality Management is also accountable for compliance with all applicable external accrediting and regulatory entities such as the:

• Centers for Medicare and Medicaid Services (CMS)
• National Committee for Quality Assurance (NCQA)
• Office of Personnel Management (OPM)
• State health and insurance departments

Organizational Structure

The organizational structure of Highmark's Health Plan Quality Management divides staff responsibilities into these distinct functional areas:

• HEDIS^®/CAHPS^®/FEP
• Clinical Outcomes, Guidelines, and Quality of Care
• Clinical Quality Assurance

The Risk and Compliance Management area – which is part of the Enterprise Risk and Governance division – also supports the quality management program from an accreditation and regulatory compliance perspective.

These areas work together with the support of staff from other departments in Highmark, as well as external support from primary and specialty care providers to continually assess and improve the quality of clinical care, safety, and service to members.

Overall Objectives of the Quality Program

The objectives of the Quality Program are as follows:

1. Continuously improve client and member experience of care, as well as their health, by anticipating and evaluating their needs and proactively aligning those needs with appropriate programs and services that reduce and/or control clinical risk.
2. Support and promote the delivery of care by providing a high-quality network of practitioners and providers.
3. Offer data-informed, evidenced-based, and comprehensive health care services and programs that are continuously improved based on outcomes.
4. Build effective partnerships with members and their caregivers/families, clients, providers, facilities, payers, and the community to understand their objectives and needs while adapting products and/or services accordingly to create positive and lasting change and a differentiated member and provider experience.
5. Utilize advanced analytics and proven quality improvement strategies and tools to measure and improve outcomes of care and service and achieve meaningful and sustainable improvement.
6. Enhance transparency efforts to promote member engagement and customer intimacy, while supporting members in making appropriate decisions about care.
7. Continue to work toward achieving health equity through reducing health care disparities, enhancing health literacy, and providing culturally and linguistically appropriate services.

Data Sources

The Highmark Quality Program provides a framework for continuous assessment and improvement of all aspects of health care delivery and services for its membership. This involves the collection and quantitative/qualitative analyses of relevant data to identify barriers or causes for less-than-optimal performance, identification of opportunities for improvement, and implementation of interventions to improve results.

Examples of the various data sources that may be collected and analyzed include, but are not limited to, the following:

1. Medical/treatment records
2. Claims
3. Enrollment reports
4. Pharmacy data
5. Condition management reports
6. Health risk appraisals
7. Member service data
8. Healthcare Effectiveness Data and Information Set (HEDIS®) results
9. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) results
10. Health Outcome Survey results
11. Utilization Management (UM) statistics
12. Member/practitioner surveys
13. Current literature

Behavioral Health

The coordination of behavioral health programs is based on an analysis of the demographic, cultural, clinical, and risk characteristics of Highmark members who utilize behavioral health services.

Highmark developed a Quality Program Description that outlines in greater detail activities to monitor and improve the quality and safety of behavioral health care and the quality of service provided to members. The document outlines the behavioral health aspects of the Quality Program and is reviewed and approved annually by the Highmark Board and appropriate Quality-related committee.

Highmark manages the inpatient utilization of behavioral health services for all members who have behavioral health care coverage through Highmark. Outpatient behavioral health services are authorized in accordance with the behavioral health benefits available for each product.

Behavioral Health Activities

Behavioral health activities have continued to include:

• Access to care and service availability for behavioral health services
• Communication standards to improve communication between behavioral health practitioners and primary care physicians to enhance continuity and coordination of care
• New and ongoing preventive behavioral health clinical initiatives
• Depression Condition Management Program

5.6 Highmark Quality Program Committees

As a way for Highmark to promote objective and systematic monitoring, evaluation and continuous quality improvement, various Highmark Program Committees have been established. The Program Committees are made up predominantly of health care professionals and are established by Highmark's Board of Directors.

Enterprise Quality, Safety, and Value Committee (EQSV)

The Enterprise Quality, Safety and Value (EQSV) Operating Committee supports the Highmark Health and Highmark Inc. EQSV Board Committee on matters impacting quality, safety, and value for the enterprise’s patients, members, and other customers. The committee’s work is to transform the enterprise’s approach to QSV from one that is focused on discrete problem solving into one that establishes and maintains a “Blended,” outcomes-driven and patient-clinician centric model across the full set of enterprise capabilities, products, and services. The Committee membership represents QSV clinical and operational expertise across all care settings, all populations, all product lines and all applicable markets. The Committee is chaired by an appointed chairperson approved by the Highmark Nominations and Governance Committee. The QSV committee provides strategic oversight to dedicated workgroups, each focused on a high-value family of measures. These specialized workgroups include Preventive Care, Pediatric Care, Cardiometabolic, Continuity and Care Coordination, among all other measures as needed, ensuring comprehensive attention to critical areas of health care quality.

Care Management and Quality Committee (CMQC)

The Care Management and Quality Committee is a multi-disciplinary committee representing Delaware; western and northeastern New York; western, central, and northeastern Pennsylvania; and West Virginia that is dedicated to continuous improvement of quality and care management services provided to members. The Senior Medical Director chairs the CMQC. Medical Directors and actively practicing physicians, including behavioral health and physicians in administrative positions with involvement in care management functions in hospitals, are active voting members.

The CMQC has responsibility for the review and approval of the quality, utilization management, and population health management program descriptions, evaluations, and action plans; relevant policies and procedures; utilization core performance indicators/trends; clinical criteria sets used by the plan and its delegates; review, leadership, and direction over Highmark’s care management activities and initiatives; relevant quality improvement activities; oversight/monitoring of all delegated utilization functions, credentialing policies, and desktop procedures as revised; and quality committee reports.

The CMQC is also responsible for recommending policy decisions, analyzing and evaluating the results of quality activities, ensuring provider participation in the quality program, instituting needed actions, and ensuring follow-up, as appropriate. This includes, but is not limited to, the results of quality monitoring activities completed specific to clinical outcomes, member experience, health care equity, member access to services, practitioner and provider availability, continuity and coordination of care, credentialing and recredentialing, delegation and business arrangement oversight, ongoing regulatory and accrediting body compliance, and review and input on clinical practice and preventive health guidelines. 

Clinical Policy Management Committee (CPMC) and Specialty Subcommittees

The Clinical Policy Management Committee (CPMC) is responsible for evaluating medical and surgical procedures and techniques, developing policy guidelines for new and evolving technology and injectable drugs, determining the medical policy coverage positions, and recommending medical necessity guidelines for covered procedures.

Specialty subcommittees are utilized to review and gather recommendations regarding medical policy coverage and criteria. The specialty subcommittees are made up of external practicing physicians. The subcommittees include but may not be limited to Cardiology, Hematology/Oncology, Musculoskeletal, Neurosciences, and Pediatrics.

New York Quality Improvement Program

The focus of the Quality Improvement Program is to continuously assess and improve the care delivered by our participating practitioners/providers and the service delivered by Highmark staff to its members. The organization has the responsibility of designing, measuring, assessing, and continually improving its performance. The result is enhanced health and well-being of the populations we serve.

New York Quality Improvement Program Scope

The scope of the Quality Improvement Program is comprehensive. It includes all Highmark members for all New York operating areas, as well as practitioners and providers who participate in the network. This includes Commercial (HMO, POS, PPO, EPO, ASO, Federal Employees Program/FEP), Medicare Advantage, and Exchange/Qualified Health Plan products and oversight of Child Health Plus, Essential Plan, and Medicaid Managed Care.

The Quality Program includes organization-wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to members. The activities include clinical, service, and patient experience.

The Enterprise Risk and Governance (ERG), Quality Management (QM), Utilization Management (UM), Health Engagement Operations (HEO), and Population Health Management (PHM) teams and programs provide a framework for continuous assessment and improvement  of various aspects of the health care delivery system. Cross-functional teams interface across the continuum to achieve shared goals, such as improving clinical outcomes and member experience, implementing a more robust quality strategy, supporting clinician-led care delivery and driving operational excellence.

5.6 Functional Areas and Their Responsibilities

The Health Plan Quality area's functions and responsibilities, outlined below, represent a core component of the broader Quality Management Program. This area actively integrates with other Highmark departments, expanding the program's scope throughout the organization.

Health Plan Quality

HEDIS/CAHPS/FEP

1. Annual HEDIS reporting to meet NCQA, QARR (NYSDOH), CMS, QRS, OPM, Pennsylvania, and New York State regulatory requirements used to assess member effectiveness of care, access to care, patient experience and utilization of preventive/chronic care services and provider compliance with national standards of care.
2. Annual NCQA HEDIS Compliance Tool (Roadmap) for all applicable products which includes a review of record of administration, data management, and processes which serve to collect information about how the plan’s information and management practices comply with HEDIS reporting requirements and associated on-site audit activities. One roadmap and audit process will be completed for the Commercial, Medicare Advantage, and Marketplace products. This audit includes a review of the health information system that is maintained to support data collection and analysis efforts for quality improvement activities. A separate roadmap and audit process for the State of Pennsylvania Children's Health Insurance Program (CHIP) product is also conducted and analyzed for quality improvement activities.
3. Completion of the NYSDOH Prenatal Medical Record Documentation Review to include medical record retrieval, data entry, analysis, and annual evaluation.
4. Quality Initiatives related to Quality Improvement Strategies (QIS) and Quality Rating Systems (QRS) for all ACA Exchange (Health Insurance Marketplace) products. NYSDOH Essential Plan Quality Incentive and Quality Improvement Strategy (QIS) to support NY Marketplace products (managed by Wellpoint, oversight by Highmark Western and Northeastern New York).
5. Clinical QARR/HEDIS outcome monitoring, analysis, and planning/design of initiatives focused on improving the care via the monthly HEDIS/Quality Oversight meeting with Wellpoint and the Clinical POEM Workgroup.
6. Annual vendor selection/management for administration and analysis of CAHPS and EES for all applicable products are maintained for identification of improvement opportunities.
7. Clinical outcome monitoring, analysis, and planning/design of initiatives focused on improving the care provided to the Federal Employee Program [Federal Employee Health Benefits (FEHP) and Postal Service Health Benefits (PSHB)] membership, with focus on targeted measures selected by the OPM for their performance improvement program.
8. Year-round medical record reviews are systematically performed to support prospective reporting, providing continuous data for performance measurement and intervention planning.

Clinical Outcomes and Guidelines (COG) and Quality of Care (QOC)

1. Clinical outcome monitoring, analysis, strategizing and planning/design of initiatives focused on improving the care provided to members, with targeted focus on NCQA HEDIS scored measures.
2. Program Outcomes Evaluation and Measure Clinical Workgroup (POEM-CWG). Preventive initiatives are developed and implemented by Clinical Quality staff through the work of the POEM-CWG. HEDIS data is reviewed, barrier analysis performed, and opportunities for improvement identified to identify gaps in care that need closing, and to improve outcomes through interventions targeted towards members and providers.
3. Preventive Health Guidelines (PHGs) are developed, published and reviewed annually to comprehensively address age-specific needs and considerations. These guidelines, which include recommendations, screenings, and interventions, are grounded in evidence-based sources, practitioner input, and Federal and Regulatory guidance, with the aim of preventing illness, detecting disease early, and improving health outcomes.
4. Facilitate the Preventive Health Workgroups (PHWG) to ensure the health plan is compliant with mandates and regulatory guidelines and complete the annual Medicare Advantage and Commercial Preventive Schedules (PS).
5. Member and provider interventions to improve health literacy.
6. Continuity and coordination of care monitoring for transitions within medical care, between medical and behavioral health care, identifying opportunities for improvement, and acting as appropriate.
7. Quality Improvement Strategy (QIS) for ACA Exchange (Health Insurance Marketplace) members.
8. Collaboration with Government Quality on the development and reporting of the Chronic Care Improvement Program (CCIP). Collaboration is also with Clinical Services on interventions that support the CCIP. The CCIP incorporates at least one activity into the Quality Program to reduce disparities in health/health care among enrollees that are broadly accessible to address relevant disparity.
9. Patient safety activity monitoring through the review of all internal and external QOC complaints.

Clinical Quality Assurance

1. Highmark Western and Northeastern New York Quality Program implementation, documentation, monitoring, analysis, and planning under the authority of the Highmark Western and Northeastern New York Quality Management Committee and the Board of Directors of Highmark Western and Northeastern New York.
2. Oversight and coordination of various quality committees including the Care Management and Quality Committee (CMQC), and the Mental Health Parity Compliance Committee.
3. Coordination of Regulatory requirements and documentation for New York Utilization Management regulatory requirements.
4. Support Utilization Management operations compliance with regulatory and accreditation requirements through monitoring, analysis, and remediation planning, including but not limited to conducting clinical quality audits to validate appropriateness of UM review, approval and medical record documentation, as well as inter-rater reliability testing and reporting for UM medical, behavioral health, and pharmacy.
5. Support Population Health Management operations compliance with regulatory and accreditation requirements through monitoring, analysis, and remediation planning.

Other Health Plan Clinical/Service Quality Activities (Medical and Behavioral Health)

The functions below are performed by various departments within the health plan/enterprise.

1. Vendor selection/management for administration and analysis for behavioral health experience.
2. Network adequacy plan maintenance and monitoring, including Marketplace products.
3. Member preventative health status assessments via claims data analysis, health-risk assessment (HRA) data, PRA-plus surveys, Medicare Health Outcomes survey (HOS) results, Personal Health Records (PHRs), etc.
4. Behavioral Health Preventive Program management, such as those proponents focused on alcohol use screening and depression screening post cardiac event.
5. Practitioner/provider interventions designed to encourage participation in CMS and HHS QI initiatives as applicable.
6. The Center for Inclusion Health and the Institute for Strategic Social and Workforce programs partner in owning the work to maintain Civil Rights Act compliance, including arrangements for language assistance services as needed; demographic analysis; Language Assistance Plan monitoring, identification of opportunities for improvement, implementation, and re-measurement.
7. Provider peer review/performance monitoring occurs through the Quality of Care/Access to Care complaint process as well as credentialing/re-credentialing functions, with regular reporting to the Quality Management Committee.

Enterprise Risk and Governance (ERG)

The scope of Enterprise Risk and Governance functions and responsibilities are described below. The functions below are maintained within the appropriate ERG teams or Highmark business areas.

1. Ongoing monitoring and continuous audit preparedness for applicable regulatory and accrediting bodies.
2. NCQA Health Plan accreditation program management for Commercial and Exchange products.
3. NCQA contract, project management, and audit coordination: coordinate, prepare, and submit documents for, and participate in, on-site and off-site quality reviews and audits conducted by applicable accrediting and regulatory bodies.
4. Delegation oversight assessment/monitoring: participate in centralized delegation oversight assessment process and ongoing monitoring specific to NCQA requirements.
5. Highmark Population Health Management Strategy that aligns with the Highmark Health strategy.
6. Communications to members and providers regarding QP goals/objectives, progress towards achieving goals, ability to provide input, etc.
7. Communications to members and providers regarding QP goals/objectives, progress towards achieving goals, ability to provide input, etc.
8. Health services contracting monitoring to ensure compliance with NCQA requirements.
9. Compliance audits of member notification of practitioner termination and continued access to care to ensure continuity and coordination of care of membership.
10. Oversight of Transition of Care (TOC) procedures to allow new enrollees of a managed care product who are currently in treatment with an out-of-network provider the opportunity to transition his/her care to a network provider.
11. Oversight of process to help inform members and providers of the potential for benefit exhaustion as well as to educate members about available alternatives for continuing care, as appropriate.
12. Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”): Highmark applies the same network admission and provider credentialing standards to all providers in a comparable manner regardless of whether the provider renders medical services, behavioral health services or substance abuse treatment services. Further, Highmark utilizes the same processes, standards, factors, and strategies to develop provider reimbursement rates for providers that render medical services, behavioral health services and substance abuse treatment services.
13. Oversight of appointment accessibility monitoring to ensure that members have appropriate access to primary care, behavioral healthcare, and specialty care services.
14. Telephone accessibility monitoring to ensure that members have appropriate access to organization services.
15. Member experience/satisfaction monitoring (e.g., dissatisfactions, complaints, appeals) and determination of service quality improvement opportunities to correct all problems identified through internal surveillance, complaints, or other mechanisms.
16. Provider satisfaction monitoring (e.g., UM process) through the review and analysis of provider dissatisfactions. Opportunities to improve provider satisfaction are identified and a plan of action implemented, if required.
17. Oversight of practitioner and provider availability monitoring to ensure an adequate network of primary care, behavioral health, and specialty care practitioners and providers is maintained, as well as how effectively the network meets the cultural, ethnic, racial, and linguistic needs and preferences of its membership.
18. Oversight of continuity and care coordination monitoring of transitions between medical care settings, and between behavioral and medical healthcare, identifying opportunities for improvement, and acting as appropriate.

New York Quality Improvement Program Authority and Structure

The ultimate accountability for the Quality Program rests with the Board of Directors of Highmark Western and Northeastern New York, Inc.

The authority and responsibilities for administration and implementation of the Quality Program are vested in the Senior Medical Director. The Corporate Quality Management Committee regularly submits reports to the Board of Directors of Highmark in New York.

QI Committee Structure

To assure that the Quality Program is implemented appropriately, key critical responsibilities related to a successful Quality Improvement Program are the shared responsibility of a variety of the committees and subcommittees across the organization.

In support of this shared responsibility, the committees, subcommittees, ad hoc committees, etc. will analyze health care-related data from monitoring activities, software program output, and formal studies as appropriate.

These committees consider a variety of actions in relation to data and a number of other activities that are defined in corporate policies. These committees include the Quality Management Committee, Network Quality and Credentials Committee, Pharmacy and Therapeutics Committee, Medical Management Clinical Committee, Vendor Process Management, Mental Health and Substance Use Disorder Parity Compliance Committee, the Behavioral Health Advisory Board Committee, Wellpoint Joint Oversight Committee, and Highmark Inc./Highmark NY Utilization Management Master Service Agreement (MSA) Joint Oversight Committee.

Monitoring and Evaluation

Results are used to compare with other local plans and regional averages, to revise goals and to target areas of improvement.

• Healthcare Effectiveness Data and Information Set (HEDIS®) measures are primarily clinical in nature, collected annually, audited by an approved contracted vendor, and submitted to NCQA, CMS, and the Blue Cross Blue Shield Association.
• Consumer Assessment of Health Plan Study (CAHPS®) survey provides a measurement of how well the plan/practitioners met members' expectations.
• Quality Assurance Reporting Requirements (QARR) is a set of measures for Commercial HMO, Qualified Health Plans (Marketplace), and Medicaid/Child Health Plus populations based on HEDIS-like data, that are collected annually and sent to the New York State Department of Health (NYSDOH).
• Medicare Star Rating is consistent with CMS’ Quality Strategy of optimizing health outcomes by improving quality and transforming the health care system. CMS uses a Five Star Quality Rating System on a scale of 1 to 5, with 5 stars being the highest score a plan can receive, and 1 star being the lowest. CMS publishes star ratings in the fall each year, and the five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality.
• Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey are a measure set comprised of clinical quality measures, including National Committee for Quality Assurance (NCQA), HEDIS® and a Pharmacy Quality Alliance (PQA) measure. The measure set also includes survey-based measures based on questions from the QHP Enrollee Survey that captures member experience and plan efficiency, affordability, and management. The quality ratings of Five Star rating scale is similar to Medicare Star Rating.

Population Health Management Strategy

A variety of clinically based programs are in place for addressing the needs of members across the continuum of care. These include health management programs to address members with complex health care needs, those with physical or developmental disabilities, multiple chronic conditions, and severe mental illness. These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagements in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals to address health disparities through cost-effective and tailored health solutions. 

Delegation

Highmark adheres to the delegation requirements outlined by various regulatory bodies, including but not limited to: NCQA and the New York State Department of Health. The appropriate organization staff reviews all pre-assessments, annual assessments, medical necessity criteria and/or clinical guidelines, program documents (descriptions and evaluations) and performance reporting activities. Relevant information on delegated activities is also shared with oversight committees and the Board of Directors, as appropriate.

Annual Evaluation of QI Program

The effectiveness of the Quality Program is evaluated on an annual basis. The Program Evaluation addresses all aspects of the Quality Program process and activities as outlined in the Program Description/Action Plan. The Quality Program Evaluation is presented to the Quality Management Committee and the Board Directors for approval. Previously identified issues and ongoing projects are incorporated into the Action Plan for the subsequent year.

QI Work Plan

The Quality Work Plan is developed based on the outcomes and recommendations of the previous evaluation of the Quality Program. The Work Plan includes previously identified issues and Quality Program objectives for the upcoming year. Each objective is measurable and includes responsible parties and time frames for anticipated completion dates. The Work Plan will be updated on a regular basis throughout the year.

5.6 Case Review Process for Quality Concerns

Highmark's Quality Management is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care.

The Clinical Quality of Care Team of Quality Management becomes aware of potential issues/concerns and member dissatisfactions about clinical quality of care issues through information received from a variety of sources, including providers, members, and internal Highmark departments.

Important

Members are able to make clinical quality of care complaints to the health plan.

The Initial Review

A Clinical Quality Management Consultant (CQMC) completes the initial review of each case referred for potential quality of care issues. The CQMC, who is a registered nurse, reviews the case to determine whether there is potential for a quality issue referencing scientifically based standards of care.

• When this initial review determines that the concern does not have the potential for an adverse outcome, the case is closed and filed for trending purposes.
• If the potential for an adverse outcome is identified, medical records are requested from the provider or facility involved in the case.

A determination will be made if a clinical review is needed and applicable information is available (i.e., DOS, permission from member to use name, name and location of provider, HIPAA, if required) or if additional clarification is needed. The member concern is then forwarded to a CMQC who will request the medical record and a written response to the concerns from the provider. In New York, the medical record request will be accompanied by a request for a written response to the concerns from the provider.

Analysis of Medical Records

Once medical records are received, the CQMC performs an assessment of the case. If the assessment dispels any concern of potential for an adverse outcome, the case is closed and filed to track the provider for any future issues.

If the potential for an adverse outcome is identified, the case is forwarded to a Medical Director for review.

Medical Director Review Outcomes

When the Medical Director believes that a quality issue may be present, a written request for additional information is sent to the provider involved.

If it is determined that a quality issue is indeed present following the review of any additional information, a Level of Harm is determined by the Medical Director, and a corrective action plan is implemented if warranted.

In New York State, an acknowledgment letter of the decision regarding the clinical complaint/concern is sent to the member.

Provider Responsibilities

During the investigation of quality of care concerns, facility providers may be asked to supply any or all of the following:

• A copy of the member’s medical or behavioral health record
• A response from the administrator, or the administrator’s designee, to address a possible adverse outcome determined during the medical record review
• A corrective action plan (if warranted) if an adverse outcome is found during the medical record review

It is the provider's responsibility to supply all requested information. Professional agreements state no fees are to be imposed for medical records needed to investigate a Clinical Quality of Care concern.

5.6 Corrective Action and Sanctioning

Issues Leading to Corrective Action or Sanctioning

A provider or facility is placed under corrective action or sanctioning when a treatment, procedure, or service indicates a provider is not practicing in a manner that is consistent with the standards of Highmark and/or deviates from acceptable standards of care.

There are two issues when a provider can be placed under corrective action/sanctioning:

1. Clinical quality of care – Occurs when an episode strays from accepted medical standards (e.g., actions or omissions resulting in an adverse effect on a patient’s well-being, medication errors, missed diagnosis, delaying treatment, unanticipated and unexplained death)
2. Administrative non-compliance – Occurs when a provider’s behavior is not consistent with their agreement with Highmark contracts and guidelines (e.g., failure to comply with contractual obligations, medical record review deficiencies, and unauthorized billing for services)

Notification of Corrective Action

Once the Medical Director makes a determination to place the provider under corrective action, the provider will be notified in writing of:

• The reason for the corrective action
• What corrective action is needed and what it entails
• The period of time the provider will remain under the corrective action

The provider can either appeal the decision of the Medical Director, elect to abide by the corrective action plan, or make the necessary improvements (if applicable).

Appeal Hearing

If an appeal is requested, a hearing with the Network Quality and Credentials Committee (NQCC) will be made available. This committee will make the decision to either uphold or overturn the original decision by the Medical Director.

Sanctioning Possible

After the corrective action time period has expired, the provider will be re-evaluated by the Medical Director. If the Medical Director is satisfied that all stipulations are met, the corrective action will be lifted.

If the stipulations are not met, sanctioning of the provider could occur, which may result in a provider’s inability to participate in certain programs.

5.6 Clinical Quality

Preventive Guidelines

Preventive Health Guidelines, which are based on scientific evidence, are available for all Highmark providers to help them in their efforts to promote healthy lifestyles and disease prevention, while reducing risk factors in the following member (patient) populations.

• Prenatal/Perinatal Guidelines
• Children Ages 0-6 Guidelines
• Children Ages 7-18 Guidelines
• Adult Ages 19-64 Guidelines
• Adult 65 and Older Guidelines
• Women's Preventive Health Services Addendum
• Perinatal Depression Prevention Counseling Coding Guidelines
• PrEP Related Services Coding Guidelines

The Clinical Outcomes and Guidelines Quality team reviews and updates the Preventive Health Guidelines on an annual basis utilizing references such as the United States Preventive Services Task Force (USPSTF), CDC, National Institutes of Health (NIH), Centers for Medicare and Medicaid Services (CMS), etc. The Preventive Health Guidelines are placed on the applicable websites via the Provider Resource Center. A notice regarding the Preventive Schedule is made available via the member website.

The Preventive Health Guidelines, along with many other valuable clinical resources, are available on the Provider Resource Center. To access these materials, go to the Provider Resource Center and select Resources and Education from the main menu, then Clinical Quality and Education.

Condition Management Program

The Condition Management Program is designed to develop a collaborative working relationship between Highmark members, members’ providers, and Highmark clinicians to support the provider’s plan of care for members under their care. The purpose of the program is to identify members who are most at risk for significant care gaps and, therefore, a progression and/or worsening of their chronic condition. High-risk members are identified through a combination of inpatient and outpatient claims, pharmacy claims, and clinical risk scores that enable our clinicians to conduct outreach to those members by telephone.

Nurses providing condition management services by telephone are known as clinicians. Clinicians work collaboratively with the member and provider to establish realistic and attainable short and long-term goals and to encourage behavior and lifestyle changes that lead to better member self-management of their condition(s).

Members may be eligible to receive health coaching for these chronic conditions, such as, but not limited to, the following:

• Asthma
• COPD
• Depression
• Diabetes
• Heart Disease
• Heart Failure
• Hemophilia
• Hereditary Angioedema
• High-Risk Pregnancy
• HIV/AIDS
• Inflammatory Bowel Disease
• Mental Health Disorders
• Metabolic Syndrome
• Musculoskeletal Pain
• Obesity
• Substance Use Disorder
• Tobacco Use

For Federal Employee Program (FEP) members, one of the following rare disease cohorts may also apply:

• Amyotrophic Lateral Sclerosis (ALS)
• Crohn’s
• Cystic Fibrosis
• Hemophilia
• Lupus
• Multiple Sclerosis
• Myasthenia Gravis
• Myositis
• Parkinson’s disease
• Rheumatoid Arthritis
• Scleroderma
• Seizures
• Sickle Cell Anemia

Providers, members, and family members can learn about the program and refer to the program by calling the 24/7 health information line using the phone number on the back of their insurance card.

Continuity and Coordination of Care

Highmark recognizes the importance of coordination of care as part of the quality continuum. There are programs and policies in place to ensure coordination of medical, behavioral health, or other community support for members. This process enables Highmark to inform the membership of health care needs that require follow-up, training in self-care, and other measures to promote their health.

Highmark facilitates the continuity and coordination of medical care across the delivery system and collaborates with behavioral health practitioners to monitor and improve coordination between medical and behavioral health care. The communication between PCPs and behavioral health specialists is assessed as part of the Highmark Quality Program.

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 PCPs when care is delivered to their patients. PCPs should expect a written description of the care given to their patients any time services have been rendered by these providers.

Medical Record Review

Any Practitioner who provides care to our members

Medical record documentation can be assessed at any time using medical record documentation standards that are based on the most recent regulatory guidelines (CMS, NYSDOH, NCQA).

OB/GYN Providers

Medical record documentation will be assessed using the most recent NYSDOH prenatal guidelines. These standards will be used to evaluate compliance in appropriate prenatal medical care for pregnant women.

Purpose

Review of these medical records will improve continuity and quality of patient care by assuring timely, legible, accurate, and comprehensive documentation of patient-provider interaction. It will allow Highmark of Western and Northeastern New York to target areas of opportunity to provide education to practitioners on their documentation and areas where medical care can be improved.

Procedure

Medical record documentation standards are based on regulatory guidelines. The standards are reviewed for updates annually.

The medical records for review can be derived from any of the following sources:

• HEDIS/QARR/QRS Review: Healthcare Effectiveness Data and Information Set/Quality Assurance Reporting Requirements/Quality Rating System. Documentation submitted to address gaps in care serves as a valuable resource for discerning emergent trends that may necessitate further investigation.
• Quality of Care Concern Review: In response to member concerns with clinical quality of care, provider medical records may be requested for review.
• Internal Department Referrals: Records identified by Clinical Services, Credentialing, and Financial Investigations and Provider Review (FIPR), as needing Clinical Quality medical record review for clinical quality of care concern.
• Continuity and Coordination of Care: Designated projects will coordinate with medical record review to obtain medical records.
• Live Birth File: Records are identified for inclusion in the NYSDOH prenatal medical record review.

Patient Safety Program Activities

Highmark recognizes the importance of patient safety programs; therefore, the Highmark Patient Safety Program focuses on the development of activities which assess and improve the plan’s patient safety efforts.

Many activities have been developed to enhance patient safety, including development of patient-safety-focused, written educational offerings for member and provider communications.

Quality of Care Case Reviews

Clinical Quality – Quality of Care is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care and for initiating appropriate action in response to them.

Clinical Quality – Quality of Care becomes aware of clinical quality of care dissatisfactions through information received from a number of sources, including providers and members as well as internal Highmark departments. Tracking mechanisms enable Clinical Quality – Quality of Care to monitor the information received over time and identify improvement opportunities.

HEDIS^®

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to ensure purchasers and consumers have the information they need to reliably compare the performance of all managed health care plans. Each participating plan reports data for the same measures, so you know you are making comparisons based on similar information.

To ensure these measures encompass data from the entire calendar year, health plans are asked to evaluate and report their results from the prior year. The Plan may be required to report on members from distinct product lines as required to meet and/or maintain National Committee for Quality Assurance (NCQA) accreditation, Centers for Medicare and Medicaid Services (CMS), and/or Office of Personnel Management (OPM) requirements, and/or the Pennsylvania and/or Delaware Department of Health and/or New York Department of Health (PA DOH, DE DOH, NYS DOH) requirements.

Understanding the categories in which plans are rated can help members make a choice based on what is important to them. HEDIS® determines quality and value by measuring success in the following areas:

• Effectiveness of Care: Assesses all types of care (preventive, early detection and screening, maternity, acute, chronic, and behavioral health as well as overuse and appropriateness of care) and populations (children, adolescents, adults, and seniors).
• Access/Availability of Care: Assesses our network providers’ accessibility and timeliness of care.
• Experience of Care: Assesses current members’ levels of satisfaction with the health plan.
• Utilization and Risk Adjustment Utilization: Assesses resource use, how efficiently care is provided, and whether needed services are being delivered.
• Health Plan Descriptive Information: Presents an overview of provider-related information and member demographics.

This reporting occurs annually and requires the use of administrative claims data, as well as supplemental data feeds through the use of electronic clinical data systems and medical record abstracted data.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

5.6 Service Quality

Member Satisfaction Monitoring

Annual member satisfaction surveys are conducted, using a statistically valid sample of the membership, to ensure that the plan identifies potential areas for service quality improvements.

Results of the survey are reviewed by Clinical Services - Quality and internal ad-hoc workgroups. The findings are then reported to the Care Management and Quality Committee. Member satisfaction is also monitored through review of member dissatisfactions, complaints, and appeals.

CAHPS^® and QHP EES Survey Results

Highmark contracts with SPH Analytics, an independent research firm certified by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS), to conduct the annual Commercial and Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Qualified Health Plan Enrollee Experience Survey (EES).

The surveys are used to gather information about the overall experiences of our members and to identify areas for improvement.

The CAHPS and QHP EES survey results are updated annually and are available on the Provider Resource Center's CAHPS/QHP EES Results page.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

5.6 Highmark Quality Initiatives

Shared Effort

Highmark considers the pursuit of quality improvement in health care to be a shared effort. While each facility must assess its own needs, establish meaningful goals, and monitor its own progress, Highmark can assist by providing data and opportunities for analysis. Highmark appreciates the cooperation of facilities in collecting data and making good use of it toward improvement of quality in health care services.

Medicare Advantage Quality Improvement Program

Highmark maintains a comprehensive Medicare Advantage Quality Improvement Program (QIP), which includes the mandatory Chronic Care Improvement Program (CCIP) as required by the Centers for Medicare and Medicaid Services (CMS). This program is designed to promote the effective management of chronic diseases across the Medicare Advantage plans. Annually, Highmark completes and attests to the effectiveness of its CCIP within the CMS Health Plan Management System (HPMS), demonstrating adherence to regulatory standards by submitting both a detailed Plan Section and an Annual Update on its progress.

Through its Quality Management teams, Highmark conducts systematic and ongoing follow-up on identified chronic conditions. For instance, a recent project focused on improving the percentage of diabetic members receiving annual diabetic retinal eye exams. This involved cross-functional teams performing quantitative and qualitative analyses, leading to targeted interventions aimed at enhancing health outcomes and participant engagement. This approach ensures continuous improvement in care delivery, aligning with CMS's objective of better health for our members.

Member Outreach Initiatives

The Clinical Outcomes and Guidelines team coordinates the development and implementation of member outreach and communication initiatives designed to promote evidence‑based preventive care, chronic disease management, and overall health improvement. Outreach activities include targeted mailings, educational materials, digital communications, and other engagement strategies that provide health information, reminders, and encouragement for recommended clinical services.

Member outreach initiatives are data-driven and prioritize populations with identified gaps in care, focusing on preventive health screenings such as breast, cervical, and colorectal cancer screenings, as well as other quality measures. Outreach strategies are tailored, when appropriate, to support accessibility, health literacy, language needs, and member preferences.

Health Care Disparities Activities

In support of reducing healthcare disparities, Highmark team collaborates with internal and external partners to identify and address inequities in access, utilization, and health outcomes across diverse member populations. Healthcare disparities activities utilize the Highmark Community Support tool to help identify members with social and community-based needs and connect them with available community resources and support services.

Member Health Care Education Materials

Highmark identified a need for Spanish-speaking members to have access to educational materials translated into their native language. Several of Highmark’s educational materials have been translated into Spanish and are available on the Provider Resource Center's Educational Resources – Member and Provider page.

Highmark is continuing to evaluate the need for other educational materials to be translated and will implement new translated materials as necessary.

Risk Adjustment Programs

Highmark has both prospective and retrospective coding programs in place to support correct risk scoring of its members. These programs are essential for ensuring the accuracy and completeness of each member's health record, allowing for appropriate risk adjustment. Highmark also provides resources and education to providers to facilitate accurate capture of ongoing conditions on an annual basis.

Goals of Risk Adjustment Programs:

• Support a complete and accurate health record
• Gap closure to engage members who may not be properly managing their chronic conditions
• Support providers to appropriately utilize Medicare Annual Wellness Visits and other encounters to complete health assessments and facilitate gap closure
• Support population health strategies

Provider documentation and coding information is available in the Clinical Quality and Education section of the Provider Resource Center.

Submitting Claims with More Than 36 Diagnosis Codes

Highmark can accept up to 36 diagnoses for a date of service. If you have more diagnosis codes than the system allows, Highmark has developed the following process to submit additional diagnosis codes:

1. Submit first claim using applicable visit CPT code(s)
2. Submit a second claim using 99499, $0.00. Include the additional diagnoses codes that went beyond the maximum codes allowed from the original claim on this new claim. Important: 99499 must be the only CPT code on this claim.
3. If appropriate, submit remaining diagnoses using 99499 with modifier 25, $0.00 on an additional claim

Example: Billing system with a maximum amount of 12 diagnoses per claim:

1. Submit first 12 diagnoses using actual visit CPT code(s)
2. Submit 13 – 24 diagnoses using 99499, $0.00
3. Submit 25 – 36 diagnoses using 99499 with modifier 25, $0.00

If you wish to submit additional diagnosis codes beyond the count of 24 by utilizing 99499 on another separate claim, a modifier 25 must be affixed to the procedure code along with a claim charge of $0.00 to avoid a duplicate claim.

• Highmark classifies 99499 as an eligible procedure code for risk adjustment within the encounter data processing system (EDPS). EDPS filtering is set by CMS, and the government agency lists only 99499 for the submission of additional diagnosis as eligible for risk adjustment. A claim only needs to have one line with an eligible procedure code in order for the entire claim, and all of its diagnosis codes, to be deemed eligible for risk adjustment. However, if 99499 is billed as a separate claim with a $0.00 charge, the diagnosis code(s) would be eligible for risk adjustment, but the separate $0.00 claim will be denied/rejected for payment as no payment can be made due to the $0 charge.
• Affix a claim charge amount of $0.00 to the procedure code. This must be the amount recorded.

Note: A denial message will show on the EOB stating that this line item could not be processed because a charge amount was not attached. Even though this line item is denied, Highmark will still capture the diagnosis codes affiliated with this procedure code. If a diagnosis code of value was omitted from the original billing, Availity® will allow you to submit the additional codes using 99499 on eligible 1500 claims.

5.6 Peer Review Protections

Protected Activities

Activities of the Highmark Quality Program, including activities of the staff, medical directors, and the Network Quality and Credentials Committee, may be afforded protections as peer review activities under state and federal law. Such protected activities include:

• Evaluating and improving the quality of health care rendered;
• Reducing morbidity and mortality;
• Evaluation by health care professionals of the quality and efficiency of services ordered or performed by other health care professionals (including inpatient hospital and extended care facility utilization review and ambulatory care review); and
• Actions or recommendations of a professional review body, based on the competence or professional conduct of a physician, which could adversely affect the health or welfare of a patient, and which could affect the clinical privileges or plan membership of the physician.

Accordingly, network providers and other peer review bodies (such as hospital quality review committees) may furnish information requested by the Highmark Quality Program and the confidentiality of such information will be maintained and protected pursuant to applicable state and federal laws.

5.6 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.

5.7 Payment Innovation

5.7 True Performance Program

5.7 Quality Blue Hospital Pay-for-Value Program

5.7 Disclaimers

5.7 Payment Innovation

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

Highmark’s value-based reimbursement strategy evaluates providers' ability to deliver the right care at the right time and in the most appropriate setting. Our value-based reimbursement programs place intense focus on care coordination and population health management principles.

Primary Care Solution

True Performance is a contracted program that replaced all previous pay-for-value and quality incentive PCP programs across all of our service areas and member populations. In True Performance, physicians are rewarded for their performance on quality and cost/utilization metrics and may be eligible to earn monthly care coordination reimbursement and quarterly or annual lump sum reimbursement.

This program is designed to continue to improve the quality of health care delivered to our members while working to reduce the overall cost of health for our members. For our provider partners, True Performance reduces the complexity of multiple programs, offers a higher performance-based reimbursement opportunity, and provides timely and actionable reporting.

For additional information, see the True Performance Program section of this unit.

Specialist Solutions

To assist in impactful referrals, PCPs receive information on the highest-value specialists through Specialist Performance, which monitors cost and detects variability in care delivery within select specialties. These specialties are associated with the highest reimbursements and, therefore, present the best opportunity to also enhance the value of the care our members receive. These cost profiles show PCPs which specialists provide the greatest value and help PCPs make more informed referral decisions. In addition, specialists will receive scorecards to help them observe care cost, detect variability in care delivery, and monitor adherence to care protocols.

Facility Value-Based Solution

Highmark’s facility-based value-based reimbursement program, Quality Blue Hospital Pay-for-Value, is operational in all service areas. The Quality Blue Hospital Program is designed to help providers align care with industry standards and best practices to better manage the care our members receive and improve outcomes. Under the Quality Blue Hospital Program, facilities contract with Highmark to place a portion of their reimbursement "at risk," dependent on their performance on rigorous clinical quality and cost measures that align with those advanced through national organizations, including the National Quality Forum (NQF) and National Committee for Quality Assurance (NCQA).

Incentives are paid on a retrospective performance basis. In addition to the clinical quality measures, the program includes measures for cost and utilization evaluation on select, high-volume episodes of care based on CMS BPCI logic and reduces wasteful spending while improving care.

See 5.7 Quality Blue Hospital Pay-for-Value Program of the Highmark Provider Manual for additional program information.

Post-Acute Solutions

Helion is an independent company that provides post-acute network management services on behalf of Highmark Inc. and certain of its affiliated health plans. Helion operates in two key areas in the post-acute space — Skilled Nursing Facilities (SNF) and Home Health (HH). The value-based reimbursement (VBR) programs have been developed for the SNF and HH care settings.

In our SNF and HH programs, our first priority is to minimize readmission rates, ensuring that members receive effective care during their initial stay. Our quality metrics emphasize timely follow-up with primary care physicians (PCPs) or specialists, as well as timely initiation of care. In addition, there is a focus to actively manage emergency department (ED) utilization, aiming to reduce unnecessary ED visits and enhance member outcomes. Lastly, SNF and HH providers are able to closely monitor and manage the measured cost of care, promoting best practices in market. Our SNF and HH models are currently operational in Delaware, Pennsylvania, and West Virginia.

Episodic Payment Model

Helion's episodic payment model (EPM) for both SNF and HH providers empowers them to earn additional incentives by caring for and managing members efficiently and effectively. The EPM is based on 30-day episodes for SNF providers and 60-day episodes for HH providers. These initiatives represent significant steps toward improving post-acute care quality and managing costs effectively. Helion will continue working to scale these successful programs across Highmark’s entire footprint.

Clinically Integrated Networks (CINs)

Highmark is supportive of Clinically Integrated Networks (CINs) and strives to partner with as many providers as possible to ensure delivery of high-quality, affordable care. We will usually encourage their formation if strategic value is created for the provider(s) involved, and will design custom arrangements for them depending on their needs and aspirations.

Highmark has advanced reimbursement models that incorporate pay-for-value, shared savings, shared risk, and capitation for entities across our multi-state service area.

5.7 True Performance Program

True Performance, Highmark’s flagship primary care pay-for-value program, offers primary care practices additional funds for managing their attributed population of Highmark members. Our True Performance value-based program is one of the largest PCP-based, private, value-based reimbursement programs in the country.

Physicians are rewarded for their performance on quality and cost/utilization metrics and may be eligible to earn monthly care coordination reimbursement, as well as quarterly or annual lump sum reimbursement. Timely and actionable reports are provided to give physicians regular insight into determining which care and referral decisions contribute to optimum results for quality, outcomes, and value.

In addition, True Performance meets the nationally consistent criteria for patient-centered, value-based care to be designated as a program of Blue Distinction Total Care, an initiative of the Blue Cross Blue Shield Association. For more information, see the Blue Distinction Programs section in the Highmark Provider Manual’s Chapter 5, Unit 1: Care Management Overview.

Participants

True Performance is a contracted program offered to entities in Highmark service areas that have at least 250 uniquely attributed pediatric, adult, and senior members, whose providers practice primary care, and who accept placement of approximately 30% of their revenue risk based on performance cost and quality metrics.

Reimbursement Opportunities

True Performance provides PCP practices with two reimbursement opportunities — Monthly Care Coordination and Performance Lump Sum.

Care Coordination is based on achieving quality thresholds for the practice’s pediatric, adult, and senior patients. It accounts for 25% of potential total program reimbursement for providers in Delaware, Pennsylvania, and West Virginia.

Lump Sum encompasses those same quality measure, plus three cost and utilization metrics — total cost per member per month (PMPM), emergency department utilization, and all-cause readmissions. Lump Sum accounts for 75% of total program reimbursement.

Participating practices that meet or exceed a minimum level of quality performance on their attributed membership receive risk-adjusted Care Coordination Reimbursement on a PMPM basis. Performance Lump Sum Reimbursement is paid on a quarterly or annual basis and is based on performance across both program components of Quality and Cost/Utilization. Calendar year performance determines the amount of Lump Sum Reimbursement earned as a percentage of maximum potential Lump Sum Reimbursement, which is based on a practice’s attributed membership.

Quality Metrics

Risk-adjusted care coordination fees are advanced monthly for each attributed member as long as a minimum quality performance on 26 quality metrics, as scored by age group (e.g., pediatric, adult, senior), is maintained.

Industry-supported quality metrics are nationally sourced from National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS) Stars and align with:

1. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Counseling for Physical Activity (Pediatric)
2. Lead Screening in Children (Pediatric)
3. Well-Child Visits in the First 15 Months (Pediatric)
4. Child and Adolescent Well-Care Visits (Pediatric)
5. Cervical Cancer Screening (Adult)
6. Eye Exam for Patients with Diabetes (Adult, Senior)
7. Breast Cancer Screening (Adult, Senior)
8. Colorectal Cancer Screening (Adult, Senior)
9. Glycemic Status Assessment for Patients with Diabetes (HbA1c) (Adult, Senior)
10. Medication Adherence for Diabetes Medication (Adult, Senior)
11. Medication Adherence for Hypertension: Renin Angiotensin System Antagonists (RASA) (Adult, Senior)
12. Medication Adherence for Cholesterol (Statins) (Adult, Senior)
13. Statin Use in Persons with Diabetes (Adult, Senior)
14. Controlling High Blood Pressure (Adult, Senior)
15. Osteoporosis Management in Women Who Had a Fracture (Senior)
16. All-Cause Readmissions (Adult, Senior)
17. Transitions of Care: Medication Reconciliation Post-Discharge (Senior)
18. Transitions of Care: Patient Engagement After Inpatient Discharge (Senior)
19. Follow Up After ED Visit for People with Multiple Chronic Conditions (Senior)
20. Kidney Health Evaluation for Patients with Diabetes (Adult, Senior)
21. Follow-up After ED Visit for Mental Illness (Pediatric, Adult, Senior)
22. Concurrent Use of Opioids and Benzodiazepines (Adult, Senior)
23. Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Senior)
24. Child Immunization Status: Combination 7 (Pediatric)
25. Adolescent Immunization Combo 2 (Meningococcal, TDAP/TD, HPV) (Pediatric)
26. Medicare Advantage Recapture Rate (Senior)

5.7 Quality Blue Hospital Pay-for-Value Program

The Quality Blue Hospital Pay-for-Value Program is a contract-based initiative in which a hospital agrees to put a portion of its Highmark reimbursement at risk, contingent upon attainment of specified objectives in the areas of quality improvement and patient safety.

Purpose

Highmark seeks to improve the health of its members by bringing to the market an innovative approach that supports providers in continuously improving the care and services delivered to their patients and our members. Highmark understands that an efficient health care delivery system promotes and maintains a high standard of quality and rewards cost-efficient care.

Highmark also understands that hospitals provide a unique opportunity to promote health care through collaboration, coordination, and communication among all providers by aligning services and enhancing the patient experience. This can be achieved by providing resource support, data sharing, aligning objectives, and encouraging care coordination across all aspects of care delivery.

Definition

The Quality Blue Hospital Program focuses on improving quality, controlling costs, and enhancing the member/patient experience. The Program components have been carefully designed to demonstrate value for Highmark, our customers and members, and our participants, and support Highmark’s mission, vision, and values.

Program Participation

Eligibility in Highmark’s Quality Blue Hospital Program requires Participants to have a current contract with Highmark.

In order to have a current contract, a hospital must meet the following criteria:

• The hospital has signed one or more Highmark network participating contracts that under the terms of such contracts will be in effect during the current contract year.
• The hospital is not in default under the terms and conditions of the aforesaid network contracts at any time during the current contract year.
• The hospital has not provided a notice of termination to Highmark or Highmark’s regulators with respect to any Highmark network participating contract and such notice provides for termination prior to June 30 each calendar year per contractual agreement.

Once enrolled in the program, contracted hospitals become eligible facility partners (hereafter, “Participants”). Participants are required to complete the following component metrics:

• Quality Bundle
• Readmissions
• 3-Day Returns to the Emergency Department (ED)
• Palliative Care for Complex Patients
• Follow-up Visits for Select Episodes of Care
• Average Episode of Care Costs for select episodes metric*

Palliative Care for Complex Patients and Average Episode of Care Costs will not be an applicable measure for Specialty Care Hospitals since they predominantly treat certain diagnoses or perform certain procedures. Hospitals with employed physician practices will be required to complete the Quality Bundle metric.

*This measure does not apply to the New York regions.

Program Components

The Quality Blue Hospital Pay-for-Value Program focuses on key public health topics that have been identified nationally as areas of opportunity for improvement. Two component categories each with specific standardized metrics have been established to address these topics and include the following:

1. Quality:
   1. Quality Bundle
   2. Clinical Quality Measures
      1. Readmissions
      2. 3-Day Returns to the ED
      3. Palliative Care Consults for Complex Patients
      4. Follow-up Visits for Select Episodes of Care
2. Cost and Utilization:
   1. Average Episode of Care Costs
      1. Major Joint Replacement of the Lower Extremity
      2. Chronic Obstructive Pulmonary Disease (COPD),Bronchitis, Asthma
      3. Esophagitis, Gastroenteritis, and Other Digestive Disorders
      4. Sepsis v. Cardiac Arrhythmia
      5. Percutaneous Coronary Intervention
      6. Simple Pneumonia and Respiratory Infections
      7. Major Bowel Procedure
      8. Spinal Fusion (non-cervical)
      9. Stroke

Program Evaluation and Scoring

Participant performance will be monitored throughout the program year and dashboard reports will be shared quarterly in an effort to provide insight for further process improvements.

The claims-based reporting methodology requires that the measurement period begins in advance of the program start date to allow for sufficient time for data collection and claim run-out so that comprehensive and complete results can be provided. Individual metric measurement periods and, when applicable, baseline information can be found in the Program manual.

A final three-month run-out period will be used on program components to identify all claims that should be included for performance measurement and scoring purposes. Participants are scored at the end of the program year.

Participants will be measured and scored on all program components for which they qualify. Participants with accountability for participating in all program component metrics have an opportunity to receive a maximum of 100 points. Participants that do not meet the criteria for inclusion in all program components (due to specific component requirements or other exclusions) will have their applicable component scores converted to a score out of 100%.

Ongoing Changes to the Program

The Quality Blue Hospital Program continually evolves to meet the needs of Highmark and participating network facilities. Accordingly, the Quality Blue Hospital Program will be reviewed and revised annually.

For More Information

For additional information regarding the Quality Blue Hospital Program, contact the Provider Service Center.

5.7 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, 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.