7.1 Medicare Advantage Member Evidence of Coverage Booklets

The Medicare Advantage Member Evidence of Coverage Booklets explain how Medicare Advantage members get their health care and drug coverage.

• Delaware, Pennsylvania, and West Virginia
  
  • Once you click on the link, enter your Zip Code to find the appropriate plan documents for your Highmark region.
• Western New York
• Northeastern New York

6.1 Disclaimers

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

7.2 Medicare Advantage Compliance Language

The regulations governing the Medicare Advantage program set forth required terms for both Medicare Advantage plans and contracted providers. In order to make contracted providers aware of such terms, the Centers for Medicare and Medicaid Services (“CMS”) has created a contracting checklist for Medicare Advantage plans to follow in developing providers’ contracts and related policies and procedures. That checklist is included in Chapter 11 of the CMS Medicare Managed Care Manual (Section 100.4), a copy of which is available on the CMS website.

In certain cases, regulatory language must be included in the actual contractual document governing the relationship between the Medicare Advantage plan and the provider. In other cases, CMS allows a Medicare Advantage plan to include required terms in its policies and procedures that are made available to contracted providers.

The provisions that follow are Medicare Advantage compliance terms included in the Highmark Senior Health Company (“HSHC”) and Highmark Choice Company (“HCC”) policies and procedures. Provider is required to comply with all such provisions, including, but not limited to, taking all necessary actions as may be specifically noted or such actions as may be required and requested by HSHC or HCC as applicable in order for HSHC or HCC, as applicable, to meet its obligations as a Medicare Advantage plan. All requirements set forth in this document shall apply to all Medicare Advantage plans, including HSHC and HCC.

1. Provider will safeguard the privacy of any information that identifies a particular member and will, and acknowledges that HSHC or HCC, as applicable, has procedures to maintain records in an accurate and timely manner. Pursuant to 42 C.F.R. § 422.118, or its successor, the following shall apply: (a) HSHC or HCC, as applicable, must establish and maintain procedures to, and Provider must, abide by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information; (b) HSHC or HCC, as applicable, and Provider must safeguard the privacy of any information that identifies a particular member; (c) HSHC or HCC, as applicable, must establish and maintain procedures, and Provider must comply with the procedures that specify, (i) for what purposes the information will be used within the organization and (ii) to whom and for what purposes it will disclose the information outside the system; (d) HSHC or HCC, as applicable, must establish and maintain procedures to, and Provider must, ensure that medical information is released only in accordance with Federal or State law, or pursuant to court orders or subpoenas; (e) HSHC or HCC, as applicable, must establish and maintain procedures to, and Provider must, maintain records and information in an accurate and timely manner; and (f) HSHC or HCC, as applicable, must establish and maintain procedures to, and Provider must, ensure timely access by Medicare Advantage members to the records and information that pertain to them. (Required by 42 C.F.R. § 422.118 or its successor).
2. HSHC or HCC, as applicable, may offer benefits in a continuation area for those members who move permanently “out of area.” (Required by 42 C.F.R. § 422.54(b) or its successor).
3. Provider will not deny, limit or condition the furnishing of a service to a member, and HSHC or HCC, as applicable, will not deny, limit or condition the coverage or furnishing of benefits to an individual eligible to enroll in HSHC’s or HCC’s, as applicable, Medicare Advantage plan(s), on the basis of any factor that is related to health status, including, but not limited to, the following: (a) medical condition, including mental as well as physical illness; (b) claims experience; (c) receipt of health care; (d) medical history; (e) genetic information; (f) evidence of insurability, including conditions arising out of acts of domestic violence; and (g) disability. (Required by 42 C.F.R. § 422.110(a) or its successor).
4. HSHC or HCC, as applicable, will make timely and reasonable payment to or on behalf of the member for emergency and urgently needed services obtained by a member from a non-contracted provider or supplier as provided in 42 C.F.R. § 422.100(b)(1)(ii) or its successor. (Required by 42 C.F.R. § 422.100(b)(1)(ii) or its successor).
5. HSHC or HCC, as applicable, will make timely and reasonable payment for renal dialysis provided by a non-contracted provider while a member is temporarily outside HSHC’s or HCC’s, as applicable, service area. (Required by 42 C.F.R. § 422.100(b)(1)(iv) or its successor).
6. HSHC or HCC, as applicable, provides Members with direct access (through self referral) to mammography screening and influenza vaccine. (Required by 42 C.F.R. § 422.100(g)(1) or its successor).
7. HSHC or HCC, as applicable, will not impose, and Provider will not collect any, costsharing on members for influenza and pneumococcal vaccines. (Required by 42 C.F.R. § 422.100(g)(2) or its successor).
8. HSHC or HCC, as applicable, does and will maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to meet the needs of the member population served. (Required by 42 C.F.R. § 422.112(a)(1) or its successor).
9. HSHC or HCC, as applicable, gives members who are women direct access to a women’s health specialist within its provider network for routine and preventive services provided as basic benefits. (Required by 42 C.F.R. § 422.112(a)(3) or its successor).
10. HSHC or HCC, as applicable, must ensure that (a) the hours of operation of its contracted providers are convenient to the members served and do not discriminate against Medicare enrollee; and (b) plan services are available 24 hours a day, 7 days a week, when medically necessary. (Required by 42 C.F.R. §422.112(a)(7) or its successor). As applicable, Provider will maintain business hours and/or ensure Provider’s services are available in accordance with the preceding requirements.
11. HSHC or HCC, as applicable, must adhere to the CMS marketing provisions contained in 42 C.F.R. § 422.80(a), (b) and (c), or its/their successor(s).
12. HSHC or HCC, as applicable, must ensure that services are provided in a culturally competent manner to all members including those with limited English proficiency or Page 3 of 6 reading skills and diverse cultural and ethnic backgrounds. (Required by 42 C.F.R. § 422.112(a)(8) or its successor).
13. HSHC or HCC, as applicable, must ensure continuity of care and integration of services through arrangements to include procedures to ensure that members are informed of specific health care needs that require follow-up and receive, as appropriate, training in self-care and other measures that members may take to promote their own health. (Required by 42 C.F.R. § 422.112(b)(5) or its successor). As applicable, Provider will comply with these procedures.
14. HSHC or HCC, as applicable, has written policies regarding the implementation of advance directive rights, including, but not limited to, a statement that providers shall document in a prominent place in the applicable Member’s medial record if the Member has executed an advance directive. (Required by 42 C.F.R. §422.128(b)(1)(ii)(E) or its successor). Provider will comply, as applicable, with that policy.
15. HSHC’s or HCC’s, as applicable, contract with CMS must contain a provision that it will provide all benefits covered by Medicare, and Provider must render services, in a manner consistent with professionally recognized standards of health care. (Required by 42 C.F.R. § 422.504(a)(3)(iii) or its successor).
16. HSHC or HCC, as applicable, must provide, and Provider shall comply with all, policies and procedures and contractual requirements providing for continuation of member health care benefits (a) for all members, for the duration of the contract period for which CMS payments have been made; and (b) for members who are hospitalized on the date HSHC or HCC, as applicable, terminates, or in the event of insolvency, through discharge. Such requirements may be met in any manner as described in 42 C.F.R. § 422.504(g)(3) or its successor. (Required by 42 C.F.R. § 422.504(g)(2)(i) and (ii), and § 422.504(g)(3) or its/their successor(s)).
17. All provider payment and incentive arrangements must be specified in the contractual arrangement between HSHC or HCC, as applicable, and Provider. (Required by 42 C.F.R. § 422.208 or its successor).
18. The payments that Provider receives from HSHC or HCC, as applicable, for covered services rendered to members enrolled in a Medicare Advantage are, in whole or part, from federal funds and, and therefore, Provider and HSHC or HCC, as applicable, are subject to certain laws as applicable to individuals and entities receiving federal funds. (Required by 42 C.F.R. § 422.504(h) or its successor).
19. HSHC or HCC, as applicable, is required to disclose information to members in the manner and the form prescribed by CMS as required under 42 C.F.R. § 422.111. (Required by 42 C.F.R. § 422.504(a)(4) or its successor).
20. HSHC or HCC, as applicable, is required to disclose all information that is necessary for CMS to administer and evaluate HSHC’s or HCC’s, as applicable, Medicare Advantage program(s) and to simultaneously establish and facilitate a process for current and prospective members to exercise choice in obtaining Medicare services. (42 C.F.R. Page 4 of 6 § 422.64(a) and § 422.504(f)(2) or its/their successor(s)). Such information includes, but is not limited to, plan quality and performance indicators for the benefits under HSHC’s or HCC’s, as applicable, Medicare Advantage program(s) including (a) disenrollment rates for members electing to receive benefits under such program for the previous two years, 42 C.F.R. § 422.504(f)(2)(iv)(A) or its successor; (b) information on member satisfaction, 42 C.F.R. § 422.504(f)(2)(iv)(B) or its successor; and (c) information on health outcomes, 42 C.F.R. §422.504(f)(2)(iv)(C) or its successor. As required and/or requested, Provider will cooperate with HSHC or HCC, as applicable, and CMS in providing any of the preceding information that is under its control and/or in its possession.
21. HSHC or HCC, as applicable, must make a good faith effort to provide notice of termination of a contracted Provider at least 30 calendar days before the termination of the effective date to all members who are patients seen on a regular basis by the applicable Provider whose contract is terminating (which in the case of a primary care provider, means all members who are patients of such provider), irrespective of whether the termination was for cause or without cause. (Required by 42 C.F.R. § 422.111(e) or its successor).
22. HSHC or HCC, as applicable, must comply with reporting requirements in 42 C.F.R. § 422.516, or its successor, and 42 C.F.R. § 422.504(l)(2) and (l)(3), or its/their successor(s), for submitting and certifying data to CMS. Provider will certify the accuracy, completeness and truthfulness of all data that HSHC or HCC, as applicable, is obligated to submit to CMS. (Required by 42 C.F.R. § 422.504(a)(8), or its successor, and § 422.504(l)(2) and (l)(3) or its/their successor(s)). As required and/or requested, Provider will further cooperate with HSHC or HCC, as applicable, and CMS in providing any of the preceding information that is under its control and/or in its possession.
23. HSHC or HCC, as applicable, must establish a formal mechanism to consult with the physicians who have agreed to provide services under HSHC’s or HCC’s, as applicable, Medicare Advantage program(s), regarding HSHC’s or HCC’s, as applicable, medical policy, quality assurance programs and medical management procedures and ensure that the following standards are met: (a) practice guidelines and utilization management guidelines are – (i) based on reasonable medical evidence or a consensus of health care professionals in the particular field; (ii) consider the needs of the enrolled population; (iii) are developed in consultation with contracted physicians; and (iv) are reviewed and updated periodically; (b) decisions with respect to utilization management are communicated to providers and, as appropriate, to members; and (c) decisions with respect to utilization management, member education, coverage of services, and other areas to which guidelines apply are consistent with such guidelines. (Required by 42 C.F.R. § 422.202(b) or its successor). In addition, HSHC or HCC, as applicable, must operate a quality assurance and performance improvement program and have an agreement for external quality review as required by 42 C.F.R. Subpart D or its successor. (Required by 42 C.F.R. § 504(a)(5) or its successor). Provider shall cooperate with all such medical policy, medical management procedures and quality assurance and performance improvement programs.
24. HSHC or HCC, as applicable, must give a physician written notice of the following when and if HSHC or HCC, as applicable, suspends or terminates an agreement under which Page 5 of 6 the physician provides services to members. The written notice must include the following: (a) the reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physicians and numbers and mix of physicians needed to maintain an adequate network; and (b) the affected physician’s right to appeal the action and the process and timing for requesting a hearing. (Required by 42 C.F.R. §422.202(d)(1) or its successor).
25. Any without cause termination by HSHC or HCC, as applicable, or Provider requires at least sixty (60) days prior written notice. (Required by 42 C.F.R. § 422.202(d)(4) or its successor).
26. HSHC or HCC, as applicable, and Provider must comply with Federal laws and regulations designed to ameliorate fraud, waste, and abuse, including, but not limited to, applicable provisions of Federal criminal law; the False Claims Act (31 U.S.C. § 3729 et. seq.); and the anti-kickback statute (42 U.S.C. § 1320a-7b(b)). (Required by 42 C.F.R. § 422.504(h)(1) or its successor).
27. HSHC or HCC, as applicable, and Provider may not employ or contract with an individual (which in the case of HSHC or HCC, as applicable, includes, as applicable, Provider) who is excluded from participation in Medicare under section 1128 or 1128A of the Social Security Act, or with an entity (which in the case of HSHC or HCC, as applicable, includes, as applicable, Provider) that employs or contracts with such an individual, for the provision of any of the following: (a) health care; (b) utilization review; (c) medical social work; and/or (d) administrative services. (Required by 42 C.F.R. § 422.752(a)(8) or its successor).
28. HSHC or HCC, as applicable, has established and will maintain (a) a grievance procedure as described in 42 C.F.R. § 422.564, or its successor, for addressing issues that do involved organization determinations; (b) a procedure for making timely organization determinations; and (c) appeal procedures that meet the requirements of this subpart for issues that involve organization determinations. HSHC or HCC, as applicable, must ensure that all members receive notification about the (a) grievance and appeal procedures that are available to them; and (b) complaint process available to the member under the QIO process as set forth under 1154(a)(14) of the Social Security Act. (Required by 42 C.F.R. § 422.562(a) or its successor). Provider will comply with Medicare requirements regarding Member grievances, appeals, and complaints and will cooperate with HSHC or HCC, as applicable, in meeting its obligations to include, but not be limited to, the gathering and forwarding of information in a timely manner as well as compliance and adherence to any decisions rendered.
29. Provider shall comply with federal laws and regulations designed to prevent, detect and correct Fraud, Waste, and Abuse, including applicable provisions of federal criminal law, the False Claims Act (31 U.S.C. § 3729 et seq., as amended by the Patient Protection and Affordable Care Act of 2010), any False Claims Act that applies to customer, and the Anti-Kickback statute (42 U.S.C. § 1320a-7b(b)), 42 C.F.R. §§422.503(b)(4)(vi), 422.504(h)(1), 423.505(h)(1).

For purposes of this Section, Abuse, Fraud, and Waste are defined as follows:

• “Abuse” shall mean actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
• “Fraud” shall mean knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347).
• “Waste” shall mean the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program.

7.2 Disclaimers

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

Excerpt Revised May 20, 2019

ARTICLE VIII

Medical Review Committee

General.

• All matters, disputes or controversies relating to the professional health services (as defined in 40 Pa.C.S.A. § 6302(a)) rendered by Health Service Doctors (as defined in 40 Pa.C.S.A. §6302(a)) located in the Commonwealth of Pennsylvania to subscribers who have coverage under contracts issued or administered by the Corporation or any company controlling, controlled by or under common control with the Corporation (individually, an “Affiliated Entity” and collectively, “Affiliated Entities”), and any questions involving the professional ethics of such Health Service Doctors, shall be considered and determined exclusively by the committee established pursuant to this Article VIII in accordance with the requirements of 40 Pa.C.S.A. § 6324(c) (the “Medical Review Committee”). The Medical Review Committee shall provide a fair and impartial forum for resolution of all matters, disputes or controversies relating to professional health services rendered by Health Service Doctors and all questions involving professional ethics.
• The Medical Review Committee also shall provide a fair and impartial forum to consider and determine any other matters, disputes or controversies, or questions involving professional ethics, that may be submitted to the Medical Review Committee as required by law or regulation, or as may be provided in any written agreement between the Corporation or any Affiliated Entity, as the case may be, and any Health Service Doctor.
• The Medical Review Committee shall operate independently of the Corporation, and the Board of Directors shall have no authority over the decisions of the Medical Review Committee. Except as otherwise provided in Section 8.8, all decisions of the Medical Review Committee shall be final and binding upon all parties to any matter, dispute or controversy, or question involving professional ethics, submitted to the Medical Review Committee and may be entered as a final judgment enforceable against the parties thereto.
• The Corporation shall, at its expense, provide reasonable resources to the Medical Review Committee to discharge its duties under these Bylaws.

Medical Review Committee Selection Committee.

• The members of the Medical Review Committee, who must satisfy the requirements set forth in Section 8.3, shall be appointed and may be removed as provided in this Article VIII by the Medical Review Committee Selection Committee (the “Selection Committee”).
• The Selection Committee shall consist of at least five (5) persons, at least a majority of whom shall be Health Service Doctors, and the balance of whom shall be subscribers who are not Health Service Doctors and who have coverage under contracts issued or administered by the Corporation or any Affiliated Entity. All Health Service Doctors who are members of the Selection Committee shall be parties to one or more professional provider agreements with the Corporation or an Affiliated Entity.
• No member of the Selection Committee may be a director, officer or employee of the Corporation or of any Affiliated Entities or a member of a Regional Advisory Board or the NEPA Advisory Board, nor may any such person have served on the Medical Review Committee during any part of the two (2) year period immediately prior to his or her appointment to the Selection Committee.
• The members of the Selection Committee shall be appointed by the Chairperson of the Board, and each shall hold office for a term of two (2) years.

Appointment of Medical Review Committee Members; Term; Removal. The Medical Review Committee shall consist of a maximum of nine (9) members, which shall be comprised of seven (7) Health Service Doctors and two (2) subscribers who are not Health Service Doctors and who have coverage under contracts issued or administered by the Corporation. Any person may submit to the Selection Committee names of prospective Medical Review Committee members; provided, however, that the Selection Committee shall not be bound to appoint any person whose name is so submitted. The Selection Committee shall make appointments to the Medical Review Committee using the following criteria:

• At least seventy-five percent (75%) of the Health Service Doctors who are members of the Medical Review Committee shall be medical doctors or doctors of osteopathy. All Health Service Doctors who are members of the Medical Review Committee, or the employer of the Health Service Doctor member, shall be parties to one or more professional provider agreements with the Corporation.
• No member of the Medical Review Committee shall be a director, officer or employee of the Corporation or of any Affiliated Entities or a member of a Regional Advisory Board or the NEPA Advisory Board. At least two-thirds (2/3) of the members of the Medical Review Committee shall have no relationship with the Corporation or any Affiliated Entities, other than, when applicable, as subscribers who have coverage through the Corporation or an Affiliated Entity or as Health Service Doctors who submit claims, or whose employer submits claims, in the ordinary course of business.
• No member of the Medical Review Committee shall have any conflict of interest that would prevent him or her from rendering a fair and impartial decision in matters, disputes or controversies, or questions involving professional ethics, between the Corporation, or, if applicable, any Affiliated Entities , and a Health Service Doctor; provided, however, that a member may be recused from individual matters, disputes or controversies, or questions involving professional ethics, in the event of any conflict of interest with respect thereto.
• No Health Service Doctor who is a member of the Medical Review Committee shall have any history of (a) material adverse utilization or claims coding determinations by the Medical Review Committee, or (b) material repayments to the Corporation or any Affiliated Entity resulting from utilization or claims coding reviews.
• The Health Service Doctors who are members of the Medical Review Committee shall be broadly representative of the various specialties whose professional health services generally are covered under health plan benefit contracts issued or administered by the Corporation or an Affiliated Entity.
• Members of the Medical Review Committee must be willing to commit to regular attendance at Medical Review Committee meetings and to devoting adequate time to Medical Review Committee business to permit them to fully understand matters, disputes and controversies, and questions involving professional ethics, coming before the Medical Review Committee and to give full and fair consideration to all matters, disputes and controversies, and questions involving professional ethics, coming before the Medical Review Committee.

8.3.7    Each member of the Medical Review Committee shall hold office for a term of two (2) years.  Prior to the end of any Medical Review Committee member’s two (2) year term, such member may be removed only for cause as determined by the Selection Committee, including, but not limited to, failure to regularly attend Medical Review Committee meetings or to devote adequate attention to Medical Review Committee matters, disputes and controversies, and questions involving professional ethics, or no longer meeting the eligibility criteria pursuant to this Section 8.3.  Vacancies on the Medical Review Committee may be filled by appointment by the Selection Committee. The Medical Review Committee member appointed shall serve the remaining unexpired term of the Medical Review Committee member replaced. 

8.3.8    Members of the Medical Review Committee and the Selection Committee shall be entitled to be reimbursed for their reasonable expenses incurred in connection with attendance at meetings of the Medical Review Committee or the Selection Committee, as the case may be, and such other compensation for their services as may be determined by the Corporate Member.

Officers of the Medical Review Committee. The Medical Review Committee shall have three officers:  a chairperson, a vice chairperson and a secretary, selected as follows:

• The Selection Committee shall appoint a chairperson of the Medical Review Committee. The chairperson shall be a member of the Medical Review Committee and shall preside at all meetings of the Medical Review Committee.
• The Selection Committee shall appoint a vice chairperson of the Medical Review Committee. The vice chairperson shall be a member of the Medical Review Committee and shall preside at meetings of the Medical Review Committee in the chairperson’s absence.  The vice chairperson also shall perform such other duties as the chairperson may assign.
• The Corporation shall provide one of its employees to serve as secretary for the Medical Review Committee. The secretary’s role shall be solely that of administrator, and not that of a member of the Medical Review Committee. The secretary shall keep the minutes of the Medical Review Committee meetings and perform the duties enumerated in this Article VIII and such other duties as the Medical Review Committee may assign.

Submission of Matters to the Medical Review Committee. All matters, disputes or controversies relating to professional health services rendered by Health Service Doctors and questions involving professional ethics shall be submitted in record form to the secretary of the Medical Review Committee. Either the Corporation or an Affiliated Entity, or a Health Service Doctor may submit an eligible matter, dispute or controversy, or question involving professional ethics, to be heard by the Medical Review Committee.

Medical Review Committee Proceedings.

Recommend a referral to any appropriate committee, board or division of any applicable state or local professional society;

Recommend a referral to an appropriate law enforcement officer or agency of any applicable federal, state or local government if the Medical Review Committee believes that a Health Service Doctor secured payment for services performed on the basis of material false information submitted with claim(s) for such services;

Recommend a referral to any applicable state professional licensure board of a Health Service Doctor;

Render a determination that the Corporation or an Affiliated Entity is or is not entitled, in whole or in part, to a refund of fees paid to a Health Service Doctor;

Render a determination that authorizes the Corporation or an Affiliated Entity to collect any refund by withholding future payments due to a Health Service Doctor;

Render a determination for the denial, removal or suspension from one or more networks of the Corporation or an Affiliated Entity as a result of (i) a finding by the Medical Review Committee that such denial, removal or suspension is appropriate or (ii) a review of a Health Service Doctor’s recredentialing application;

Render a determination of the eligibility of the Health Service Doctor for reimbursement of certain services pursuant to the applicable privileging requirements of the Corporation or an Affiliated Entity; or

Recommend any such other determination or take any other action as may be necessary or appropriate.

Violation of any of the Health Service Doctor’s professional provider agreements with the Corporation or an Affiliated Entity or any regulations of the Corporation or an Affiliated Entity applicable to participating providers; or

Violation of any statute with which the Corporation or an Affiliated Entity or the Health Service Doctor is required to comply.

Pursuant to this Article VIII, upon a Health Service Doctor exhausting all other administrative remedies pursuant to the Health Service Doctor’s provider agreements, the Medical Review Committee shall serve as the final and binding hearing body for all matters, disputes or controversies relating to the professional health services rendered by the Health Service Doctor, and for any questions involving the professional ethics of the Health Service Doctor.

Following the submission of an eligible matter, dispute or controversy, or question involving professional ethics, to the Medical Review Committee, the Corporation or the applicable Affiliated Entity shall prepare a position statement setting forth the relevant facts and any claims against the Health Service Doctor and the rationale for the decision, which shall be sent to the Health Service Doctor prior to the Medical Review Committee hearing. The Health Service Doctor shall be permitted to file a response in record form, which shall be filed with the secretary of the Medical Review Committee.  The procedural guidelines of the Medical Review Committee shall further set forth the procedures and timeline to be followed by the Corporation or an Affiliated Entity, as the case may be, and the Health Service Doctor prior to the Medical Review Committee hearing.

The secretary of the Medical Review Committee or the secretary’s designee promptly shall fix a time, date and place for such hearing of the Medical Review Committee. The applicable Health Service Doctor shall be given at least thirty (30) days’ notice in record form by the secretary of the Medical Review Committee of the date, time and place of such hearing and shall be furnished with a copy of the position statement of the Corporation or an Affiliated Entity, as the case may be, and all relevant documentation with respect thereto.

The Health Service Doctor shall be afforded a reasonable opportunity to be heard before the Medical Review Committee. Parties before the Medical Review Committee may be represented by counsel, may present arguments, evidence and witnesses, and shall have an opportunity to question the other side’s witnesses at the hearing (which may be held by means of conference telephone or other electronic technology by means of which all persons participating in the hearing can hear and be heard by each other); provided, however, that formal rules of evidence or procedure are not required to be followed.

If a decision by the Medical Review Committee is reportable to the National Practitioner Data Bank, the Health Service Doctor may request that a court reporter be present for the proceeding, and the Corporation will arrange for the court reporter to record the proceedings.

In connection with any such hearing, the Medical Review Committee may consider any:

• Violation of the Health Service Doctor’s agreement(s) with the Corporation or an Affiliated Entity to render health care services or supplies to subscribers;
• Violation of any statute, regulation, policy or procedure with which the Corporation or an Affiliated Entity or the Health Service Doctor is required to comply;
• Violation of any of the regulations or requirements referenced in the Health Service Doctor’s agreement(s) with the Corporation or an Affiliated Entity or coding requirements with which the Health Service Doctor must comply, including coding guidance issued by independent organizations overseeing such codes; or
• Refusal to adhere to the billing, payment or service benefit provisions of any agreement issued by the Corporation or an Affiliated Entity which utilizes the applicable professional provider network in which the Health Service Doctor has agreed to participate.

Promptly following the hearing, the Medical Review Committee shall take whatever action it deems appropriate, based on the evidence and testimony produced at the hearing. The decision of the Medical Review Committee shall be sent to the Health Service Doctor within thirty (30) days of the hearing.

• The Medical Review Committee shall maintain written procedural guidelines to assure that each Health Service Doctor receives fair and impartial consideration of any matter, dispute or controversy, or question involving professional ethics, presented to the Medical Review Committee.
• Only the Health Service Doctors who are members of the Medical Review Committee may vote on any matter, dispute or controversy, or question involving professional ethics, brought before the Medical Review Committee.
• At least one-half (1/2) of the voting members of the Medical Review Committee shall constitute a quorum for the transaction of business, and the acts of a majority of voting members of the Medical Review Committee present at a meeting at which a quorum is present shall constitute the acts of the Medical Review Committee.
• The Medical Review Committee shall annually set the dates and locations of its regular meetings.
• Special meetings of the Medical Review Committee may be called at any time by the chairperson of the Medical Review Committee. The secretary of the Medical Review Committee or the secretary’s designee shall provide notice of any special meeting of the Medical Review Committee at least thirty (30) calendar days prior thereto and shall state the reason for the special meeting and the date, time and place of the meeting. For regularly scheduled and special meetings of the Medical Review Committee, members shall attend in person unless excused. If attendance in person is excused, members of the Medical Review Committee may participate by conference telephone or other electronic technology by means of which all persons participating in the meeting can hear and be heard by each other.
• In considering any matter, dispute or controversy relating to professional health services rendered by Health Service Doctors, or any question involving professional ethics brought before it, the Medical Review Committee shall make decisions in accordance with the law, relevant contracts, the applicable policies and procedures of the Corporation or an Affiliated Entity, as the case may be, and, if applicable, guidance issued by independent organizations.
• The Medical Review Committee shall have authority to take any one or more of the following actions (subject to any binding contractual prohibitions or restrictions agreed to in writing by the Corporation, or an Affiliated Entity, as the case may be):
• If a particular matter, dispute or controversy relating to professional health services rendered by a Health Service Doctor or a particular question involving professional ethics includes any actual or alleged action or failure to act which would justify denying a Health Service Doctor registration with the Corporation or an Affiliated Entity pursuant to 40 Pa.C.S.A. § 6324(a), or the suspension or termination of such registration, the Corporation or the Affiliated Entity, as the case may be, may request that a hearing be held by the Medical Review Committee in accordance with Section 8.8 to consider such registration status. Such action or failure to act may include by way of example and not limitation:
•  

Proceedings Involving Status of Registered Health Service Doctor.

• The procedures set forth in this Section 8.8 shall apply in all cases in which the Corporation or an Affiliated Entity or the Health Service Doctor has requested that a hearing of the Medical Review Committee be held to determine the status of an individual as a registered Health Service Doctor pursuant to 40 Pa.C.S.A. §6324(a). In any such case, the Corporation or the applicable Affiliated Entity shall prepare an appropriate position statement setting forth the relevant facts and any claims against the Health Service Doctor pursuant to Section 8.7.2. The procedures set forth in Section 8.7 shall be applicable to this Section 8.8.
• All testimony shall be recorded and a complete record shall be kept of the hearing.
• Following the hearing, the Medical Review Committee shall take whatever action it deems appropriate, based on the evidence and testimony produced at the hearing. If such action involves either the denial of registration as a Health Service Doctor with the Corporation or any Affiliated Entity or the suspension or termination of such registration, the matter shall be referred promptly to the Secretary of the Commonwealth of Pennsylvania Department of Health for approval or for such other action as said Secretary of Health may deem to be appropriate. The Health Service Doctor shall be notified of the decision within thirty (30) days of the hearing.

7.3 Disclaimers

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

Highmark Inc. (“Highmark”), doing business as Highmark Blue Shield, operates under the provisions of Act 271 of 1972 (40 PA. C.S. Section 6301 et seq.). Section 6324 (c) of the Act requires that all matters, disputes or controversies relating to professional health service doctors or any questions involving professional ethics shall be considered and determined only by health service doctors selected in a manner prescribed in the Bylaws of the professional health service corporation involved.

The Bylaws of Highmark Inc. (Article VIII) stipulates that the Medical Review Committee be formed to consider and determine all matters, disputes or controversies relating to the professional health services (as defined in 40 Pa.C.S.A. § 6302(a)) rendered by Health Service Doctors to subscribers who have coverage under contracts issued by Highmark, and any questions involving the professional ethics of such providers. The Bylaws of Highmark Inc. further direct that the Medical Review Committee shall maintain written procedural guidelines, which are set forth below.

The matters referred to the Medical Review Committee generally concern disputes with respect to overutilization and/or misutilization of services, coding of services rendered, professional ethics, credentialing, claims overpayments, failure to document services and other controversies relating to professional health services.

The following procedural guidelines are applicable to the Medical Review Committee:

1. For matters involving potential overutilization and/or misutilization of services or inappropriate quality of care, a review is conducted of the provider's practice pattern prior to referral to the Medical Review Committee. During this process, a sample of patient records, statistics, diagnostic aids, and/or other informational sources is reviewed. The results of such review, as well as the methodology used, will be made available to the provider when any adverse findings result. Should the provider disagree with the results of the review due to the sample size, the provider may request an expanded review.
2. If it is determined that an overpayment has been made, the amount of the overpayment will be calculated for a period of time not to exceed that permitted by the four-year Statute of Limitations governing contract claims. The results of such overpayment calculations will be made available to the provider. The provider will be furnished with the methodology used to calculate the overpayment. 
3. If it is discovered in the review process that an underpayment has occurred, the provider may seek reimbursement, through the appropriate appeal mechanisms, for all claims involved during the same time period as the review by Highmark. Such claims must be supported by clinical records.
4. If the matter is not referred for prosecution, and does not involve the proposed suspension or termination of a participating/preferred/network provider, a Highmark representative will send a letter to the provider summarizing all findings and advising the provider of available appeal rights. The provider is furnished with a written statement outlining the basis of any refund demand. The provider is also advised of the repayment options available to him or her, and is provided with a copy of these Review Committee Guidelines. The provider will be encouraged to submit any additional information which could have a bearing on the matter and/or create the basis for an adjustment to the refund amount demanded, if any. If Highmark and the provider are unable to reach an agreement concerning the amount of any overpayment or any other matter relating to the review, Highmark will send a certified mail letter to the provider, furnishing at least thirty (30) calendar days’ advance notice of the date of the Medical Review Committee meeting at which the provider's case will be considered and determined. Highmark’s letter shall also notify the provider of his or her rights to appear before the Medical Review Committee and be represented by legal counsel. The provider will again be encouraged to provide any information which may be pertinent to the resolution of the matter, dispute or controversy. Accompanying the letter is another copy of the basis of any refund demand, the applicable sections of the Bylaws of Highmark Inc. pertaining to the Medical Review Committee, the Review Committee Guidelines and, if applicable, the Preferred Provider Agreement and/or Regulations for Preferred Providers and/or credentialing policies.
5. At least fifteen (15) calendar days prior to the date of the Medical Review Committee meeting at which the provider's case will be considered and determined, the provider will be given either a hard or electronic copy of the documentation to be provided to the Medical Review Committee.
6. A provider may forward information to the Medical Review Committee and/or may appear before the Medical Review Committee. A provider who chooses to appear before the Medical Review Committee will be notified of the date and time of his or her appearance at least fifteen (15) calendar days prior to the meeting. Such notification will inform the provider of the proceeding and the provider's right to appear before the Medical Review Committee to express the reasons why he or she disagrees with Highmark’s determination and/or to provide any other information which will aid the Medical Review Committee in its determination of the matter, dispute or controversy.
7. Upon providing Highmark with at least ten (10) calendar days’ advance written notice, a provider may request that the Medical Review Committee postpone consideration of the matter, dispute or controversy until the next scheduled Medical Review Committee meeting. If, due to an emergency or other unanticipated circumstance, the provider’s request is delivered to Highmark fewer than ten (10) calendar days before the meeting, the Medical Review Committee Chairperson will decide whether there is good cause to grant a postponement. As a general rule, a provider shall be granted only one postponement to hear a particular matter, dispute or controversy. A second postponement may be granted by the Chairperson only if the second request results from unanticipated circumstances beyond the provider’s control. Within thirty (30) calendar days after the Medical Review Committee meeting, the provider will be advised in writing of all determinations made by the Medical Review Committee as to the matter, dispute or controversy. Such notification will include, but not be limited to, the amount of any overpayment or underpayment at issue and any other information the Medical Review Committee deems appropriate.
8. If the provider fails to refund any overpayment amounts within thirty (30) calendar days after notification of the Medical Review Committee's determination, Highmark shall be authorized to withhold payments otherwise due the provider and to assess interest. Interest will also be assessed on installment payment arrangements. Interest shall accrue on any unpaid balance at a rate equal to the then-prevailing United States Prime Rate as published in the “Money Rates” section of the Wall Street Journal print edition on January 1 of each year. If the Wall Street Journal is not published on January 1, then the next available edition of the Wall Street Journal will be used. The Prime Rate as determined by the Wall Street Journal on January 1 (or the next available edition, if necessary) shall be fixed as the interest rate for the entire calendar year until the following year’s Prime Rate is published by the Wall Street Journal.
9. If the Medical Review Committee determines that a hearing should be held to consider a question involving professional ethics or to determine whether a provider should be suspended or terminated as a participating provider, the proceedings will be conducted as set forth in Article VIII, Section 8.7, of the Bylaws of Highmark Inc., and in the manner described in these guidelines.

7.4 Disclaimers

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