What's New in the Highmark Provider Manual 

Chapter 2, Unit 3: Other Government Programs

• In 2.3 Highmark Healthy Kids (CHIP):
  • The ID card images in the Highmark Healthy Kids (CHIP) ID Cards section were updated to reflect that as of Oct. 1, 2024, the assigned PCP will no longer appear on the member ID card.
  • In the Accessibility Expectations for Highmark Healthy Kids (CHIP) Providers section, the following tables were updated:
    • Highmark Healthy Kids (CHIP) PCP and Medical Specialist Expectations
    • Highmark Healthy Kids (CHIP) Obstetrics and Gynecology (Ob/Gyn) and Maternity Care Expectations
    • Highmark Healthy Kids (CHIP) Behavioral Health Provider Expectations
• 2.3 New York Medicaid, HARP, CHP, and Essential Plan (title updated from "2.3 New York Medicaid and CHP") now reflects the additions of the Health and Recovery Plan (HARP) and Essential Plan to the western New York service area.

Chapter 5, Unit 6: Quality Management

• In 5.6 Highmark Quality Program Committees, the New York Quality Improvement Program Scope section was updated to indicate oversight of the following programs: Child Health Plus, Essential Plan, and Medicaid Managed Care.
• In 5.6 Functional Areas and Their Responsibilities, the following changes were made under Clinical Services Quality:
  • Updates were made to the HEDIS/CAHPS/FEP section. New York is included with the other Highmark states for Healthcare Effectiveness Data and Information Sets (HEDIS^®)-related documentation and audit reporting. There will be one HEDIS Roadmap for Highmark; New York products — including Essential Plan — are now included in the reporting for Highmark’s Commercial, MarketPlace, and Medicare products.
  • A Clinical Quality Assurance section was added.
  • In the Enterprise Risk & Governance Functions and Responsibilities section, information about the New York Mental Health and Substance Use Disorder Parity Compliance Program was removed, as it is no longer a separate program and, instead, has been integrated within the Highmark corporate level committee.

Chapter 1, Unit 2: Online Resources & Contact Information

• In 1.2 Contact Information, the contact information in the Financial Investigations & Provider Review (FIPR) section was updated for Delaware, New York, and Pennsylvania.

Chapter 2, Unit 2: Medicare Advantage Products & Programs

• In 2.2 Prescription Drug Coverage Under Medicare Advantage, a Medicare Prescription Payment Plan section was added. The Medicare Prescription Payment Plan (MPPP) is a new payment option for Medicare members that works with Highmark’s Part D drug coverage to help members manage out-of-pocket costs. The MPPP was created by the passage of the Inflation Reduction Act and is effective Jan. 1, 2025.

Chapter 3, Unit 2: Professional Provider Credentialing

• In 3.2 Reconsiderations and Appeals:
  • The Reconsideration of a Credentials Committee Decision section was made applicable to Pennsylvania only.
  • The following changes for Delaware and West Virginia were made to the Appeals of Credentials Committee Decisions section:
    • All appeals of Credentials Committee decisions for Delaware and West Virginia professional providers will be presented to the Highmark Network Quality and Credentials Committee (NQCC).
    • Appeals will no longer be presented to the Appeals Review Committee. The reconsideration step was removed.

Chapter 2, Unit 6: The BlueCard Program

• In 2.6 What is the BlueCard Program?, the following information was added to the Highmark Networks Supporting BlueCard section:
  • Northeastern New York:  Northeastern New York Provider Networks support the BlueCard Program.
  • Western New York:  Western New York Provider Networks support the BlueCard Program.
• In 2.6 NAIC Codes, information for Pennsylvania NAIC code 15460 was updated.

Chapter 3, Unit 1: Network Participation Overview

• In 3.1 Introduction to Network Participation, Medicare Advantage was added as a network for acupuncturists in Delaware, Pennsylvania, and West Virginia.

Chapter 4, Unit 1: PCPs and Specialists

• In 4.1 Treatment of Immediate Relatives, the language was updated to further define the eligibility of services provided to immediate relatives.

Chapter 5, Unit 3: Medicare Advantage Procedures

• In 5.3 Preservice Organization Determinations, acupuncture was removed from the Exceptions to Preservice Organization Determination Requirements section.

Chapter 6, Unit 2:

• In 6.2 NAIC Codes, information for Pennsylvania NAIC code 15460 was updated.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In 5.5 - Filing an Appeal on Behalf of a Member, the section on Decision Time Frame was updated.

Chapter 3, Unit 2: Professional Provider Credentialing

• The following updates occurred in the sections listed below:
  • 3.2 Highmark Network Credentialing Policy > ADMITTING AND CLINICAL PRIVILEGE REQUIREMENTS – Physician assistant specialist was added to the list of specialties that waive the hospital clinical privilege requirement.
  • 3.2 Highmark Network Credentialing Policy > TIME FRAME – Time frames for credentialing application procedures were updated for the following regions: Massachusetts, New York, Ohio, and West Virginia.
  • 3.2 Practitioner Quality and Board Certification > HIGHMARK RECOGNIZED BOARDS FOR CERTIFICATION – American Board of Orthodontics (ABO) was added to the list of Highmark recognized boards for certification.

Chapter 4, Unit 7: Medical Records Documentation Requirements

• In 4.7 Additional Requirements to Support E/M Services, language in the CODING GUIDELINES FOR E/M SERVICES section was updated to reflect coding guidance effective Jan. 1, 2023, based on medical decision-making or time considerations.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In 5.5 Filing an Appeal on Behalf of the Member, the timeline for responses to non-urgent appeals in Pennsylvania and West Virginia was clarified in the DECISION TIME FRAME section to: 10 business days for preservice appeals and 30 calendar days for post-service appeals.

Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips

• In 6.4 Anesthesia Reporting Tips, language stating the ANESTHESIA RELATED TO OBSTETRICAL CARE section applied to Medicare Advantage Providers Only was removed. Also, the list of procedure codes was updated to include additional identified codes.
  

Chapter 7, Unit 7: Medicare Advantage Supplemental Requirements

• As part of the consolidation to one Provider Resource Center, the Medicare Advantage Supplemental Requirements document was moved to the Highmark Provider Manual - Chapter 7: Appendix. It is a supplemental document to Highmark's Medicare Acute Care Provider Agreement and is applicable to providers in Pennsylvania and West Virginia only.

Chapter 3, Unit 2: Professional Provider Credentialing

• Changes were made to clarify the eligibility of Licensed Social Workers and other specialties regarding credentialing vs. enumeration in the following sections:
  • 3.2 Highmark Network Credentialing Policy > MID-LEVEL AND ADVANCED PRACTICE PROVIDER (APP) ENUMERATION
  • 3.2 Credentialing Requirements for Behavioral Health > LICENSED CLINICAL SOCIAL WORKER REQUIREMENTS

Chapter 4, Unit 7: Medical Records Documentation Requirements

• 4.7 Durable Medical Equipment and 4.7 Prosthetics were combined into one section — 4.7 Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) — and the following information was updated/added:
  • Prescribers should update their documentation for the length of time DMEPOS is indicated for use every six months.
  • Dispensing Prescriptions: Standing orders are not permitted and should be written specific to the member's condition, unless otherwise stated in relevant medical policy.
  • Customization and Modifications: Manufacturer order forms must be included when a prescribing provider or supplier orders a specific type of DME, orthotics, or prosthetics for a member to support the item/device and the modifications or customizations added to the base item/device.
  • An ADDITIONAL ORTHOTICS GUIDELINES section was added and states that in addition to the requirements outlined in the DMEPOS section, documentation of relevant physical exams is required.

Chapter 5, Unit 3: Medicare Advantage Procedures

• In 5.3 Notice of Medicare Non-Coverage (NOMNC), the language was updated to reflect that the Centers for Medicare and Medicaid Services is requiring insurers to collect additional documentation from facilities for Quality Improvement Organization (QIO) program audits, effective Jan. 1, 2024. Specific instructions for locating the following forms were also included in this update:
  • Notice of Medicare Non-Coverage (NOMNC)
  • Detailed Explanation of Non-Coverage (DENC)

Chapter 5, Unit 6: Quality Management

• In 5.6 Functional Areas and Their Responsibilities, the following change was made to the NEW YORK QUALITY IMPROVEMENT PROGRAM AUTHORITY AND STRUCTURE section under “QI Committee Structure”: The name of the Amerigroup Joint Oversight Committee was changed to Wellpoint Joint Oversight Committee to reflect the vendor’s new corporate name.

Chapter 5, Unit 7: Value-Based Reimbursement Programs

• In 5.7 Payment Innovation (DE, PA, and WV Only):
  • The POST-ACUTE SOLUTIONS section was updated to reflect that HM Home & Community Services is now known as Helion. In addition, updates were made to the value-based reimbursement (VBR) program descriptions, along with the regions where they are offered, as Helion has scaled these offerings across Delaware, Pennsylvania, and West Virginia.
  • An EPISODIC PAYMENT MODEL section was added.

Chapter 6, Unit 8: Payment Review

• In 6.8 Financial Investigations and Provider Review (FIPR), a new fraud hotline number (800-352-9100) was added for Delaware and Pennsylvania. Some minor wordsmithing changes were also made to this section.

Accessibility Expectations Update

All Accessibility Expectations were updated to align across all markets. These changes were applied to the following chapters and units in the Highmark Provider Manual:

• Chapter 1, Unit 4: Highmark Member Information > 1.4 Member Access to Physicians and Facilities > ACCESSIBILITY EXPECTATIONS FOR PROVIDERS
• Chapter 4, Unit 1: PCPs and Specialists > 4.1 PCP and Medical Specialist Accessibility Expectations > ACCESSIBILITY EXPECTATIONS FOR PROVIDERS
• Chapter 4, Unit 2: Behavioral Health Providers > 4.2 Accessibility Expectations for Behavioral Health > ACCESSIBILITY EXPECTATIONS

The updated expectations are in bold text below.

1. PCP and Medical Specialists Expectations
   1. Urgent Care Appointments updated to “Immediate Response.”
   2. PCP Non-urgent Care Appointments updated to read as “Non-urgent, regular care appointments must be scheduled within 48-72 hours (three days).
   3. Regular and Routine Care Appointments updated to read as “Routine Care Appointments” must be scheduled within three weeks of the member request.
      1. Additional bullet added: Subsequent routine wellness appointments must be scheduled within seven days of member request.
   4. New expectation added: Follow-up visit requires care within five days of discharge or as clinically indicated.
2. Behavioral Health Provider Expectations
   1. Urgent Care Appointments updated to “Immediate Response.”
   2. Non-urgent Care Appointments updated to read as “Non-urgent, regular care appointments must be scheduled within 48-72 hours (three days).
   3. Regular and Routine Care, initial visit was updated to read as “Routine or Initial visit” must be scheduled within seven days of the member request.
      1. Additional bullet added: Subsequent routine wellness appointments must be scheduled within seven days of member request.
   4. New expectation added: Follow-up visit requires care within five days of discharge or as clinically indicated.

Chapter 2, Unit 6: The BlueCard Program

• In 2.6 Contiguous County Contracting and Overlapping County Contracting, updates were made to reflect all of the Highmark regions in which another Blues Plan operates. Language was also added to provide clarity on claims submission.

Chapter 5, Unit 1: Care Management Overview

• In 5.1 Enhanced Community Care Management (ECCM), the program description was updated.
  • NOTE: This section was also updated to remove West Virginia as an applicable state. ECCM is only available in Delaware and Pennsylvania.

Chapter 1, Unit 2: Online Resources & Contact Information

• In 1.2 Mailing Addresses, “Claims Filing Addresses” documents that were linked under the CLAIMS FILING ADDRESSES heading were removed. That information is now included in tables in that section.
  • NOTE: The newly added tables include Federal Employee Program (FEP) addresses. For that reason, the FEP addresses were removed from 1.2 Contact Information, which now includes language referring providers to 1.2 Mailing Addresses.

Chapter 2, Unit 2: Medicare Advantage Products & Programs

• In 2.2 Highmark Medicare Advantage Products, the following changes were made:
  • Separated the NENY Medicare Advantage PPO network from the Freedom Blue PPO network, which is in Delaware, Pennsylvania, and West Virginia.
  • Replaced the Senior Blue HMO network with the NENY Freedom HMO network for Northeastern New York.
  • Added the Together Blue HMO network in Western Pennsylvania.
  • Corrected the name of Western New York’s WNY Medicare Advantage HMO.
  • Corrected the coverage of WNY Forever Blue PPO to only cover Western New York’s service area.

Chapter 3, Unit 2: Professional Provider Credentialing

• In 3.2 Highmark Network Credentialing Policy, a link to Reimbursement Policy (RP)-068 was added to the ADVANCED PRACTICE PROVIDER (APP) ENUMERATION section.

Chapter 4, Unit 2: Behavioral Health Providers

• In 4.2 General Information, the Behavioral Health contact information, including both fax and phone numbers, was updated for all Highmark service regions.

Chapter 5, Unit 4: Behavioral Health

• In 5.4 Retrospective Review, the Retrospective Review mailing address for mental health and substance use disorder treatment was updated for Delaware, Pennsylvania, and West Virginia.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In 5.5 Expedited Provider Appeal Process, the phone number to initiate an expedited provider appeal was updated for Delaware, Pennsylvania, and West Virginia.
• In 5.5 Standard Provider Appeal Process:
  • The phone number to initiate a standard provider appeal was updated for Delaware, Pennsylvania, and West Virginia.
  • The mailing address for Behavioral Health Services (all service areas) was updated for post-service appeals and Federal Employee Program (FEP) provider appeals.

Chapter 6, Unit 3: Facility (UB-04/8371) Billing

• In 6.3 Present on Admission/Adverse Events, a link to RP-036 was added to the REIMBURSEMENT POLICY RP-036 section.

Relinquishment of Washington County, Ohio

Highmark Blue Cross Blue Shield in West Virginia relinquished the Washington County, Ohio, service area. The change — which was requested by Highmark — was approved by the Blue Cross Blue Shield Association (BCBSA) in November 2023.

For this reason, references to Washington County, Ohio, were removed from the following areas of the manual:

• 1.1 About Highmark
• 1.2 Highmark Websites (PUBLIC WEBSITES section)
• 2.1 Introduction (HIGHMARK’S CORPORATE ENTITIES section)
• 3.1 Directing Care to Network Providers (LOCATING NETWORK PROVIDERS section)

Chapter 6, Unit 3: Facility (UB-04/8371) Billing

• In 6.3 Outpatient Services Prior To An Inpatient Stay, a link to Reimbursement Policy (RP)-039 was added to the REIMBURSEMENT POLICY RP-039 section.

Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips

• In 6.4 Modifiers:
  • A link to RP-001 was added to the ASSISTANT AT SURGERY: MODIFIERS 80, 81, 82, & AS section.
  • A link to RP-002 was added to the CO-SURGERY: MODIFIER 62 section.
• In 6.4 Anesthesia Reporting Tips, a link to RP-033 was added to the MEDICAL DIRECTION (SUPERVISION) OF ANESTHESIA REPORTING/PAYMENT* section.
• In 6.4 Reporting Mid-Level Provider Services for Medicare Advantage (PA and WV Only), links to RP-001, RP-010, and RP-068 were added to the REIMBURSEMENT FOR SERVICES PERFORMED BY MID-LEVEL PROVIDERS section.

Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, fax references related to prior authorization for West Virginia were removed from the Highmark Provider Manual.

Chapter 5, Unit 1: Care Management Overview

• In 5.1 High-Risk Maternity (NY Only), the following changes occurred:
  
  
  • A link to the New York State Department of Health prenatal assessment form (which only applies to Highmark Blue Cross Blue Shield members in Western New York) was provided.
  • The phone number for Interventions for High-Risk Patients was updated to 800-871-5531.
  • The hyperlink for the Health Commerce System was updated.
  • Under the LABORATORY REPORTING REQUIREMENTS section, language was updated to align with recent changes made to 5.1 Practice Guidelines and Standards of Care for HIV (NY Only).
    • The email for reporting required data elements was updated to BHAELab@health.ny.gov.
    • The hyperlink for the NYS DOH HIV/AIDS Provider Portal was provided.
  • Additional minor wordsmithing and formatting changes were made.

Chapter 5, Unit 6: Quality Management

• In 5.6 Functional Areas and Their Responsibilities, the language was updated to reflect that the Senior Medical Director is solely responsible for administration and implementation of the Health Care Quality Improvement Program, as the position of Vice President Health Management has been eliminated.

Chapter 3, Unit 2: Professional Provider Credentialing

• In 3.2 Termination from the Networks, a MEMBER NOTIFICATION section was added to indicate that a provider’s patients (who are Highmark members) will automatically be notified via U.S. Mail when that provider is terminated from the Highmark provider network.

Chapter 3, Unit 3: Professional Provider Guidelines

• 3.3 How to Resign from Network Participation was updated to indicate that providers must use the electronic Request to Terminate a Contracted Network form if they decide to resign from the Highmark provider network. Other methods, including fax, have been eliminated. In addition, when providers decide to resign from the Highmark provider network, their patients — who are Highmark members — will be automatically notified via U.S. Mail.

Chapter 5, Unit 1: Care Management Overview

• In 5.1 Practice Guidelines and Standards of Care for HIV (NY Only), there were numerous updates, including:
  • Lower threshold for recommending HIV testing: Providers should now adopt a lower threshold for recommending HIV testing, as many patients may not be comfortable disclosing risk factors.
  • Updated resources: The manual now includes updated links and contact information for HIV testing resources, including the AIDS Institute NYSDOH Counseling and Testing Resources and the NYSDOH AIDS Institute Resource Directory.
  • New HIV reporting requirements: Healthcare providers are now required to report any HIV diagnosis within one day and complete the Medical Provider HIV/AIDS and Partner/Contact Report Form within seven days.
  • Improved laboratory reporting requirements: Laboratories are now required to report HIV-related test results with more detailed patient information to improve data quality and linkage to care.
  • Updated reporting timeframe for suspected seroconversion: The timeframe for reporting suspected seroconversion has been updated from 14 days to seven days.

Chapter 5, Unit 2: Authorizations

• In 5.2 Authorization Guidelines, the VENDOR DELEGATION AND OVERSIGHT section was updated, as file audits are now conducted on a monthly, rather than a quarterly, basis.
• In 5.2 Emergency Services, the following addition was made to the EMERGENCY CARE DEFINED section:
  • "Any condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act, including with respect to a pregnant woman who is having contractions — that there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child."

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In 5.5 Grievances and Appeals (NY Only), a few minor changes were made, including correcting a typo on the section title, “APPEALING AN UPHELD DENIAL (LEVEL II).”

Chapter 6, Unit 1: General Claim Submission Guidelines

• 6.1 Self-Funded Accounts, which had been specific to West Virginia, was updated to be applicable to all Highmark service regions.

Chapter 3, Unit 2: Professional Provider Credentialing

• In the ADMITTING AND CLINICAL PRIVILEGE REQUIREMENTS section of 3.2 Highmark Network Credentialing Policy, “Hospice & Palliative medicine” was added to the list of specialties for which the hospital clinical privilege requirement is waived.
• In the ADDITIONAL BEHAVIORAL HEALTH SPECIALTIES CRITERIA section of 3.2 Credentialing Requirements for Behavioral Health, “licensed” was added to the requirements for the specialty of Marriage and Family Therapist.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• The information in the following sections was updated to include Delaware as an applicable region:
  • 5.5 Medicare Advantage: Provider Appealing on Own Behalf (DE, PA, and WV Only)
  • 5.5 Medicare Advantage: Appeals on Behalf of a Member (DE, PA, and WV Only)

Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips

• In 6.4 Anesthesia Reporting Tips, the language was updated to align with Reimbursement Policy 033 (RP-033): Anesthesia Services. The Physical Status Units table was enhanced, while the section on Modifying Units was eliminated.

All references to naviHealth in the Provider Manual have
been changed to Home & Community Care Transitions to reflect the company's name change. Home & Community Care Transitions is a third-party vendor used by Highmark for post-acute care services for Highmark's Medicare Advantage members in Pennsylvania and West Virginia.

Highmark finalized changes to the Provider Manual related to the provider portal transition from NaviNet and HEALTHeNET (NY) to Availity. NaviNet and HEALTHeNET (NY) access for providers ended on April 26, 2024.

Chapter 2, Unit 6: The BlueCard Program

• In 2.6 Itemized Bills Required for High-Dollar Host Claims, the amount considered a high-dollar claim was changed from “$100,000 or greater” to “$50,000 or greater.”
• In 2.6 NAIC Codes, changes were made to the PENNSYLVANIA NAIC CODE PROVIDER TYPE PRODUCTS table to align with information in Chapter 6, Unit 2: Electronic Claim Submission > 6.2 NAIC Codes. The table was updated to include the following information:
  • For 54771W, the Northeastern region was added.
  • For both 54771W and 54771, prefixes were added to these products:
    • Medicare Advantage Security Blue HMO-POS (prefixes JOF, JOL)
    • Together Blue Medicare HMO (prefix K9P)
    • Medicare Advantage Community Blue Medicare HMO administered by Highmark Choice Company (prefixes ZPM, KHC)
  • For 54771C, prefixes (ZPM, KHC) were added to Medicare Advantage Community Blue Medicare HMO administered by Highmark Choice Company.
  • 54771S for Southeastern region facility type providers (UB-04/837I) was added.
  • For 15460, this product was added:
    • Medicare Advantage Complete Blue PPO (prefix C4K)
  • Minor wordsmithing changes were made to both the 2.6 NAIC Codes and 6.2 NAIC Codes sections of the Highmark Provider Manual.

Chapter 3, Unit 2: Professional Provider Credentialing

• In 3.2 Highmark Network Credentialing Policy, the ADVANCED PRACTICE PROVIDER (APP) ENUMERATION section was updated to point providers to Reimbursement Policy 068 (RP-068): Mid-Level Practitioners and Advanced Practice Providers for more information instead of Reimbursement Policy 010 (RP-010).

Chapter 5, Unit 4: Behavioral Health

• In 5.4 Retrospective Review, the address for New York’s Utilization Management Appeals Unit was updated in the table in the MAILING ADDRESS section.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In 5.5 Standard Provider Appeal Process, the address for New York’s Utilization Management Appeals Unit was updated in the table in the MAILING ADDRESSES section.
• In 5.5 Filing an Appeal on Behalf of the Member, the address for New York’s Utilization Management Appeals Unit was updated in the table in the WRITTEN REQUESTS section.

Chapter 5, Unit 6: Quality Management

• In 5.6 Quality Management Program Overview, the ORGANIZATIONAL STRUCTURE section was updated to reflect current functional areas of the Quality Management Program. In addition, the OVERALL OBJECTIVES OF THE QUALITY PROGRAM section was updated with appropriate language.
• In 5.6 Highmark Quality Program Committees, the CARE MANAGEMENT AND QUALITY COMMITTEE (CMQC) section was updated to add clarification that the committee represents “western and northeastern” New York.
• In 5.6 Functional Areas and Their Responsibilities, the CLINICAL SERVICES – QUALITY section was updated with current department names and responsibilities for each area.
• In 5.6 Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations, “Representatives” replaced “Management Analysts” in the following sentence in the PRACTICE SITE RESOURCES section: The Practice Site Resources materials are used by Highmark Clinical Quality Representatives to educate the practitioner office designees when performing office site and medical record documentation reviews.

Chapter 6, Unit 2: Electronic Claim Submission

• In 6.2 NAIC Codes, minor wordsmithing changes were made to align with information in Chapter 2, Unit 6: The BlueCard Program > 2.6 NAIC Codes.

Chapter 2, Unit 2: Medicare Advantage Products & Programs

• In 2.2 House Call Program, information regarding the House Call program was updated, including:
  • The program is available to members in Highmark’s Affordable Care Act and Medicaid lines of business — not just Medicare Advantage.
  • The participating vendors were updated.

Chapter 2, Unit 6: The BlueCard Program

• In 2.6 NAIC Codes, New York state information was added, including NAIC Code 55204, as well as claim submission procedures for Empire/Anthem and Excellus members when treated by Highmark providers.

Chapter 6, Unit 1: General Claim Submission Guidelines

In 6.1 Timely Filing Requirements, the New York Timely Filing Policy section was updated. Language was clarified to emphasize that all initial claims (original bill type) must be submitted within 365 days, including weekends, from the date of service/discharge. In addition, all corrected claim submissions (bill type ending in 7) must be received within 365 days from the last date of processing of the original claim submission, including weekends.

Chapter 6, Unit 2: Electronic Claim Submission 

In 6.2 Submitting Claims (NY Only), the Claim Adjustment Policy and Exclusions to This Policy sections were removed to align New York with Highmark’s overall claim adjustment policy.

Chapter 6, Unit 8: Payment Review

• The following New York-related updates were made:
  • In 6.8 Financial Investigations and Provider Review (FIPR), a second New York fraud hotline number was added.
  • In 6.8 Payment Review Process, New York was added as part of the participating, preferred, and managed care networks Highmark is required to monitor.
  • In 6.8 Retroactive Denials and Overpayments, a New York Stte Insurance Law section and a Provider Recovery Process section for New York were added.
  • In 6.8 Post-Payment Dispute Resolution Process – Appeals and External Reviews:
    • The Appeal Rights in New York section was updated.
    • Information on New York member appeal rights was removed, as similar content is available in Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals.

Chapter 2, Unit 5: Telemedicine Services

• Throughout this unit, all references to Doctor on Demand were removed, as the vendor’s relationship with Highmark ended on December 31, 2023. Other telemedicine services provided by Amwell — along with the applicable member benefit — were added to this section, including:
  • Urgent Care within the Telemedicine Service Benefit
  • Behavioral Health within Outpatient Mental Health
  • Primary Care under PCP/Physician Office Visit
  • Dermatology under Specialist Office Visit
  • Women’s Health
    • Medical Care under Telemedicine Service
    • Therapy under Outpatient Mental Health
    • Lactation under Preventive Adult Care

Chapter 3, Unit 1: Network Participation Overview

In 3.1 Introduction to Network Participation, the Additional Providers Eligible in NY section was updated to add the following:

Effective January 1, 2024, Licensed Mental Health Counselors (LMHC) are also eligible in Medicaid and Medicare Advantage networks.

Effective January 1, 2024, Psychoanalysts with a Psychoanalyst license are eligible in all commercial networks.

• In 3.1 Promise Enrollment Required for Pennsylvania Chip, the Your Promise  ID Is Automatically Added to Highmark’s Provider File section was revised to reflect that practitioners no longer need to update their Promise ID with Highmark, as Promise ID updates are submitted electronically to Highmark by the Pennsylvania Department of Human Services.

Chapter 3, Unit 2: Professional Provider Credentialing

• In 3.2 Highmark Network Credentialing Policy, the following changes were made:
  • Types of Professional Providers Credentialed section:
    • Licensed Dietitian – Nutritionists are not eligible for NY Medicaid.
    • Licensed Psychoanalysts are recognized by Highmark as a credentialed allied health professional in New York only.
• Under 24/7 Availability Requirements, the following specialties were added as exempt:
  • Certified Diabetic Educators
  • Massage therapists
  • Psychologists who perform neuropsychological testing or psychological evaluations only
  • Read-only practitioners
• Availability for Urgent and Routine Care section:
  • Requirement for a minimum of 20 office hours a week — when not joining an existing group network — only applies to networks in Pennsylvania.
  • PCP practices in Pennsylvania not meeting this requirement will be subject to an on-site review every three years and will be noted in the provider directory as having limited hours.
• The Time Frame – Highmark West Virginia Participating Practitioners section was removed, as it is no longer a requirement for West Virginia.
• A Time Frame – Massachusetts section was added.
• In 3.2 The Credentialing Process, the following change was made:
  • Under Steps in The Initial Credentialing Process, Step 4 was updated to remove the following from the list of what the Credentialing Department will review applications for:
    • Ability to enroll new members.
    • Office hour availability of at least 20 hours/week (PCP)
• In 3.2 Credentialing Requirements for Behavioral Health, the following changes were made:
  • A Licensed Psychoanalyst section was added. Effective January 1, 2024, psychoanalysts must be licensed as a psychoanalyst in New York.
  • Under Additional Behavioral Health Specialties Criteria, “Behavioral Analysts/Behavioral specialists licensed or certified per state regulation” was added.
• In 3.2 Practitioner Quality and Board Certification, under Highmark Recognized Boards for Certification, National Board of Physicians and Surgeons (NBPAS) was added.

The Quick Reference/Contact Guide was updated to include Provider Service and Clinical Service numbers for our Southeastern Pennsylvania (SEPA) region. The NAIC code for SEPA facility claims was also added to the following sections of the manual:

• Chapter 2, Unit 6: The BlueCard Program - NAIC Codes
• Chapter 2, Unit 6: The Bluecard Program - BlueCard Quick Tips
• Chapter 6, Unit 2: Billing & Payment - Electronic Claim Submission - NAIC Codes

The new NAIC code was communicated to providers via Special Bulletin on November 30, 2023.

Chapter 2, Unit 4: Benefit Plan Programs

• Mentions of the vendor Sharecare and its offering, The RealAge^® Test, were removed from the 2.4 Health Promotion Programs section due to the relationship with Highmark ending on December 31, 2023. As part of this change, the 2.4 Highmark Wellness Rewards section was also removed.

Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals

• In response to Pennsylvania Acts 146 and 68, grievance processes and nomenclature have been updated throughout this unit.

Information related to WholeHealth Living, a Tivity Health company, was removed from the Highmark Provider Manual because utilization management of physical medicine services is now managed by Highmark.

For more information, read our Special Bulletin and Frequently Asked Questions.

Chapter 5, Unit 2: Authorizations

• Changes were made throughout the 5.2 West Virginia Gold Card Program section due to West Virginia Senate Bill 267.
  • West Virginia Senate Bill 267 requires prior authorizations to be submitted via an electronic portal. For more information on the bill, visit https://www.wvlegislature.gov.

Chapter 7, Unit 6: Professional Regulations

The Highmark Blue Shield Regulations for Participating Providers, PremierBlue Shield Providers and Government Sponsored Program Providers were updated. The Highmark Professional Provider Agreement Regulations were added with an effective date of January 1, 2024.

Chapter 2, Unit 1: Product Overview

• In the 2.1 Value-Based Benefits (DE, PA, WV Only) section, the following changes were made:
  • “Depression” was removed from under Targeted Conditions.
  • Under Program Options Continue To Expand, a paragraph that referenced outdated “packages” was deleted.

Chapter 3, Unit 4: Organizational Provider Participation (Facility/Ancillary)

The Organizational Provider Participation, Credentialing, and Contracting Requirements document, which is hyperlinked in 3.4 Participation and Credentialing > Requirements and 3.4 Applications > Facilities and Ancillary Providers, was updated.

Note: This document is also available on the Organizational Initial Credentialing Set Up PRC page (DE, PA, WV) and the Facility/Ancillary (Organizational) Initial Credentialing Set Up PRC page (NY).

Chapter 5, Unit 2: Authorizations

In the 5.2 Federal Employee Program (FEP) Prior Authorization Requirements section, the following changes were made:

• Under Other Services Requiring Prior Authorization, a document containing a table that lists FEP services requiring prior authorization or notification was mislabeled as a “Tip Sheet.” All references mentioning a Tip Sheet were deleted.

Chapter 1, Unit 3: Electronic Solutions: EDI & Availity

• Language was clarified and updated in the following sections:
  • In 1.3 Introduction under EDI Services and Availity®, outdated language regarding vendors and computer equipment was deleted.
  • In 1.3 Electronic Data Interchange (EDI), the table under Highmark EDI Services was updated with electronic transaction ID 275, along with its name.
  • In 1.3 About Trading Partners under Trading Partner Types, language was added that emphasized the importance of keeping provider and trading partner contact information updated.
  • In 1.3 Getting Started with Electronic Claim Submission under Selecting A Practice Management System Vendor, outdated language regarding computer equipment was removed.

Chapter 1, Unit 4: Highmark Member Information

• In 1.4 Member Access to Physicians and Facilities:
  • Under Accessibility Expectations for Providers:
    • The table for PCP and Medical Specialist Expectations was updated to reflect that on-call arrangements with another Highmark credentialed participating practitioner is acceptable for after-hours care.
    • The table for Behavioral Health Specialist Expectations includes updated language for after-hours care that allows for a referral to a crisis line/center if prior arrangement has been made to reach the provider. This change applies to all four states in Highmark’s footprint.
• The table under Acceptable After-Hours Methods reflects the change that an answering service — in addition to paging providers — can also transfer after-hours calls to them or another clinical staff person.

Chapter 2, Unit 6: The BlueCard Program

In the 2.6 NAIC Codes section, the Pennsylvania NAIC Code Provider Type Products table was updated to include the product prefix — Medicare Advantage Complete Blue PPO (Prefix C4K) — for code 15460.

Chapter 4, Unit 1: PCPs and Specialists

• In the 4.1 PCP and Medical Specialist Accessibility Expectations section:
  • Under Accessibility Expectations for Providers, the table for PCP and Medical Specialist Expectations was updated to reflect that on-call arrangements with another Highmark credentialed participating practitioner is acceptable for after-hours care. This applies to all Highmark regions, including those in New York.
    • Similar changes were made to the table under Acceptable After-Hours Methods.

Chapter 4, Unit 2: Behavioral Health Providers

• In the 4.2 Accessibility Expectations for Behavioral Health section:
  • Under Accessibility Expectations, the table for Behavioral Health Provider Expectations includes updated language for after-hours care that allows for a referral to a crisis line/center if prior arrangement has been made to reach the provider. This change applies to all four states in Highmark’s footprint.
    • Similar changes were made to the table under Acceptable After-Hours Methods.

Highmark has started to make changes to the Provider Manual as part of the transition from NaviNet to Availity. Changes will continue through the transition period.

Chapter 7 – Appendix

• Chapter 7, Unit 6: Professional Regulations – which includes a link to the following document: Highmark Blue Shield Regulations for Participating Providers, PremierBlue Shield Providers and Government Sponsored Program Providers – was added to the Highmark Provider Manual. This was done to increase visibility of the document, originally published to the Provider Resource Center in a January 8, 2020, communication.

Chapter 1, Unit 4: Highmark Member Information

• In 1.4 Confidentiality of Member Information, a Confidentiality of Provider and Member Information and Medical Records section was added for New York.

Chapter 5, Unit 6: Quality Management

• In 5.6 Clinical Quality, a Medical Record Review section was added for New York.

Chapter 6, Unit 2: Electronic Claim Submission

• The 6.2 Submitting Claims (NY Only) section was updated under Claim Adjustment Policy. The policy for New York was clarified to reflect that providers have 365 days from the date of service, rather than end of the calendar year, to request an adjustment or submit a correction on a claim.

Chapter 1, Unit 4: Highmark Member Information

• In the 1.4 Confidentiality of Member Information section, the following language regarding robocalls to our call centers was added: "Highmark Inc. and its affiliated companies do not release information to artificial intelligence agencies. We will be glad to provide the information needed to the appropriate human stakeholders. Please have a human use our self-service tools available at highmark.com, through our provider portal, or call Customer Service for any information needed."

Chapter 6, Unit 1: General Claim Submission Guidelines

In the 6.1 Top Billing Errors – And How to Avoid Them section, minor changes were made to the table under Common Claims Reporting Errors. Those changes include spelling out acronyms and updating the years used in examples.

Chapter 6, Unit 2: Electronic Claim Submission

• In the 6.2 NAIC Codes section under New York, clarifying language was added for claims submitted on behalf of Empire/Anthem members who are seen in the following counties: Albany, Clinton, Columbia, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington. These counties comprise the 13 counties of the Highmark Blue Shield of Northeastern New York service region.

Chapter 2, Unit 6: The BlueCard Program

• In the 2.6 NAIC Codes section, the Pennsylvania NAIC Code Provider Type Products table was updated. Prefixes were added to the following products for facility and other providers in Central and Western Pennsylvania:
  • Medicare Advantage Security Blue HMO-POS (prefixes JOF, JOL)
  • Medicare Advantage Community Blue Medicare HMO (prefixes ZPM, KHC)
  • Together Blue Medicare HMO administered by Highmark Choice Company (prefix K9P)

Chapter 3, Unit 2: Professional Provider Credentialing

• In the 3.2 Highmark Network Credentialing Policy section, language under 24/7 Availability Requirements was updated to reflect that a referral to a crisis line/center is acceptable as long as the provider or his/her designee can be reached.
• In the 3.2 Credentialing Requirements For Facility-Based Providers section under Facility-Based Practitioner Credentialing Policy, updates were made to the credentialing policy for facility-based practitioners and include the following changes:
  • In-Network Credentialing: The following types of facility providers must be currently credentialed by an in-network skilled nursing facility, ambulatory surgery center, inpatient hospital, and/or inpatient freestanding facility setting:
  • Anesthesiologists
  • Emergency medicine specialists
  • Oral maxillofacial pathologists
  • Oral maxillofacial radiologists
  • Pathologists
  • Radiologists
• Out-of-Network: To provide medical services to members outside of a network-participating facility, practitioners will be required to complete the initial credentialing and contracting processes.

Chapter 3, Unit 4: Organizational Provider Participation (Facility/Ancillary)

In the 3.4 Urgent Care Centers/Medical Aid Units section, language under Billing Guidelines was updated to reflect that Federal Employee Program members do not have coverage for code S9088.

Chapter 6, Unit 2: Electronic Claim Submission

• In the 6.2 NAIC Codes section:
  • The Pennsylvania table was updated. Prefixes were added to the following products for facility and other providers in Central Region and Western and Northeastern Regions:
    • Medicare Advantage Security Blue HMO- POS (prefixes JOF, JOL)
    • Medicare Advantage Community Blue Medicare HMO (prefixes ZPM, KHC)
    • Together Blue Medicare HMO administered by Highmark Choice Company (prefix K9P)
• The New York table was updated. Plan codes were eliminated from the table. The remaining code is NAIC Code 55204.Language was clarified for claims submitted on behalf of Excellus members who live in the following four counties that were specified in this update: Clinton, Essex, Fulton, and Montgomery.

Chapter 5, Unit 1: Care Management Overview

• In the 5.1 Introduction to Care Management section, “Wellness” replaced “Health Promotion (except in New York)” in a bulleted list of core services.
• In the 5.1 High-Risk Maternity (NY Only) section:
  • Under Benefits for Physicians,Mothers and Their Babies, a link to the Preventive Health Guidelines page of the Provider Resource Center was added. There, the High-Risk Maternity clinical practice guidelines are included in the Prenatal/Perinatal Care Preventive Health Guidelines.
  • Under Postpartum Visit Components, links for supporting documentation were updated.
• In the 5.1 Practice Guidelines and Standards of Care for HIV (NY Only) section
  • Under Aids Institute Nysdoh Counseling and Testing Resources, the phone number for HIV Counseling was updated.
  • Under Pregent Women and Exposed Infans Lost-to-Care Require Immediate Action for Re-Engagement, the phone number for the New York State Department of Health Perinatal HIV Prevention Program was updated.

Chapter 5, Unit 2: Authorizations

• In the 5.2 Authorization Request Process section:
  • Under Home-Health Authorization Requests, the language was updated to reflect that authorization procedures for Delaware, Pennsylvania, and West Virginia are the same for each region. Previous language gave the appearance that there were different regional procedures.
  • Under Telephone Requests, the contact information was updated. Professional providers should use the phone numbers for the appropriate Medicare Advantage program.

Chapter 5, Unit 6: Quality Management

• In the 5.6 Functional Areas and Their Responsibilities section, the committee list under QI Committee Structure (for providers in New York) was updated to include Highmark Inc./Highmark NY Utilization Management Master Service Agreement (MSA) Joint Oversight, and Network Quality and Credentials Committee.
• In the 5.6 Case Review Process for Quality Concerns section, language under Important! (for providers in New York) was updated to: “Members are able to make clinical quality of care complaints to the health plan.”
• In the 5.6 Clinical Quality section under Condition Management Program,HIV/AIDS was added to the list of chronic conditions for which members are eligible to receive health coaching. 

Chapter 4, Unit 1: PCPs and Specialists

• The 4.1 PCP And Medical Specialist Accessibility Expectations section was updated under Accessibility Expectations for Providers.For Urgent Care Appointments, the Performance Standard was changed from “Office visit within 1 day (24 hours)” to “Immediate response” in the PCP and Medical Specialist Accessibility Expectations table.

Chapter 4, Unit 2: Behavioral Health Providers

• The 4.2 General Information section was updated under Contact Information. The contact information for Highmark Behavioral Health (BH) Services was updated to include a fax number for Delaware (DE), Pennsylvania (PA), and West Virginia (WV). In addition, Highmark BH Services no longer offers Sunday hours of operations.

Chapter 5, Unit 4: Behavioral Health

• The 5.4 General Information section was updated under Contact Information. The contact information for Highmark Behavioral Health (BH) Services was updated to include a fax number for Delaware (DE), Pennsylvania (PA), and West Virginia (WV). In addition, Highmark BH Services no longer offers Sunday hours of operations.
• The 5.4 Services Requiring Authorization section was updated under Inpatient Service. The bullet point for inpatient rehabilitation was updated to include "mental health treatment."
• The 5.4 Authorization Requests section was updated under NaviNet^® Authorization Request SubmissionRequired (applicable to providers in DE, PA, and WV) to include the following language: "However, if NaviNet is unavailable or the facility is not NaviNet-enabled, authorization reviews can be initiated by calling Highmark Behavioral Health Services at 1-800-258-9808 or faxing 1-877-650-6112."

Chapter 6, Unit 2: Electronic ClaimSubmission

• The 6.2 Submitting Claims (NY Only) section was updated under Claim Adjustment Policy. The policy for New York was corrected to reflect that providers have 365 days, rather than 180 days, to file a claim adjustment request. This policy was implemented on January 1, 2022.

The section on Additional Diagnostic Code Reporting (New York Only) of Chapter 6, Unit 1 (General Claim Submission Guidelines) was updated to include a qualifying statement within the subsection on Sleep Studies noting that for Chemotherapy, Transfusion, Cast Room, Infusion Therapy and Treatment Rooms - the service could pay up to $50 per day for a room charge.

This qualifying statement was in the Provider Manual on the HealthNow provider websites, but was inadvertently omitted when transitioned to the Highmark Provider Resource Center websites. 

The section on High-Risk Maternity - NY Only of Chapter 5, Unit 1 (Care Management Overview) was updated to include additional guidance under Interventions for High-Risk Patients. The following language was added: "After a total of no more than two (2) missed prenatal or one post-partum visit by the member, providers can call for Case Management assistance to request active member outreach at 877-878-8785 Monday through Friday 8 a.m. to 5 p.m. EST."

The new web-based Highmark Provider Manual was published on May 23, 2023.