Highmark Provider Manual Changes

Below is a timeline of changes made to the Highmark Provider Manual. They are organized by date the changes were implemented, with the most recent changes at the top of the page.

Always refer to the entire Highmark Provider Manual for complete guidance on policies and procedures for all providers participating in Highmark’s networks.


February 21, 2024

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 STATE 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.

 

January 29, 2024

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.

 

December 15, 2023

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 a Special Bulletin on November 30, 2023.

 

December 8, 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.

 

December 4, 2023

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.

 

December 1, 2023

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.

 

November 30, 2023

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.

 

November 17, 2023

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.

 

October 27, 2023

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.

 

October 23, 2023

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.

 

October 12, 2023

Chapter 7 – Appendix

 

October 6, 2023

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.

 

September 21, 2023

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.

 

September 5, 2023

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.

 

August 24, 2023

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.

 

July 26, 2023

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 PREGNANT WOMEN AND EXPOSED INFANTS 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.

 

July 20, 2023

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.

 

June 23, 2023

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 SERVICESThe bullet point for inpatient rehabilitation was updated to include "mental health treatment."
  • The 5.4 Authorization Requests section was updated under NAVINET® AUTHORIZATION REQUEST SUBMISSION REQUIRED (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 Claim Submission

  • 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.

 

June 7, 2023

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.

 

May 24, 2023

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."

 

May 23, 2023

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

Last updated on 2/21/2024 1:13:07 PM

 

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