November 2024

Encourage Protection from Respiratory Syncytial Virus (RSV)

RSV usually causes mild symptoms, but in some cases, it can cause severe illness. Many of our Highmark Wholecare members may be at a greater risk of complications from RSV. Continue reading to learn more about what vaccines are approved for various member groups.

Care management

Supporting Patients with Seasonal Affective Disorder (SAD)

November is Seasonal Affective Disorder (SAD) Awareness Month. We encourage providers to recognize the symptoms of SAD and recommend appropriate treatment options. There are helpful resources available to assist our Highmark Wholecare members suffering from SAD.

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Vendor updates

Reminder: Highmark Wholecare Will have a New Vision Vendor

Starting January 1, Highmark Wholecare will have a new vision vender. VSP (Vision Service Plan, Inc.) will be joining our Highmark Wholecare network. If vision providers would like to continue participating with our Medicaid and Medicare D-SNP networks, please visit the VSP Provider Hub to complete the necessary registration forms and review VSP’s policies and procedures.

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Coding and claims

Billing and Coding Guidelines for Transitional Care Management (TCM)

TCM is designed to assist patients in the critical 30 days after discharge from an inpatient or facility-based setting in order to prevent readmissions and ensure continuity of care. There are two CPT codes and a number of guidelines that must be followed when billing for TCM services.

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Policy refresher

Billing for Obstructive Sleep Apnea Under Medicaid Home Oxygen Therapy Services

Highmark Wholecare Medicaid may provide coverage under the Durable Medical Equipment (DME) benefits for medically necessary Home Oxygen Therapy (HOT) services. This policy addresses documentation, clinical requirements necessary, and billing for use of oxygen gas cylinders, liquid oxygen, and oxygen concentrators.

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Important information

• Highmark Wholecare is Changing How We Verify Our Provider Directory Information

• REMINDER: EVV Providers Now Using HHAeXchange

• Don’t Miss the HWPE 2024 Medicaid Fourth Quarter Bonus Campaign

The Provider News email is sent at the end of each month to share simple and consolidated updates about Highmark Wholecare member programs, provider policies, claims, reimbursement, and more.

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For Your Reference

• Policy Updates

• Model of Care Training Summary

• Notice of Practice/Practitioner Changes

• Please Complete the Cultural Competency Data Form

• Encounters Submissions

• Medicare Parts A and B Cost Sharing

• Important Phone Numbers

VSP Vision is a separate company that administers the vision benefit(s) for Highmark Wholecare.

This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 17 counties in northeastern Pennsylvania, 13 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

Highmark Wholecare, 120 Fifth Ave., Pittsburgh, PA 15222

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