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Several times annually, Highmark notifies providers of important policies and guidelines.
The following notifications are for your information and reference.
Highmark and participating network physicians annually review and update the Preventive Health Guidelines and Clinical Practice Guidelines, which are distributed to the practitioner community as a reference tool to encourage and assist you in planning your patients’ care.
To help make the information more accessible and convenient for you, we post the complete set of guidelines online. Just visit highmarkbcbswv.com 
and click Provider Resource Center under Helpful Links. (NaviNet® users, simply click on Resource Center from the Plan Central page.) Next, go to Education/Manuals, and then select Clinical Practice and Preventive Health Guidelines.
The Preventive Health Guidelines include:
There are Clinical Practice Guidelines for the following conditions/patient needs:
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Please ask your clinical support staff to bookmark this web page as a handy reference tool to help plan your patients’ care. To obtain a paper copy of the guidelines, write to:
Highmark
Barb Cole, Director, Accreditation and Compliance
Fifth Avenue Place
120 Fifth Avenue, Suite P4425
Pittsburgh, PA 15222
Highmark makes utilization review decisions based only on the necessity and appropriateness of care and service and the existence of coverage. In addition, Highmark does not reward practitioners, providers, Highmark employees, or other individuals conducting utilization review for issuing denials of coverage or service, nor does it provide any financial incentives to utilization management decision-makers to encourage denials of coverage.
Highmark uses resources such as nationally recognized clinical review criteria, medical policy, and Medicare guidelines in determining whether a requested procedure, therapy, medication, or piece of equipment meets the requirements of medical necessity and appropriateness. This is done to ensure the delivery of consistent and medically appropriate health care for our members.
If a PCP or specialist requests a service that a clinician in Utilization Management is unable to approve based on criteria/guidelines, the clinician will refer the request to a Highmark Physician Reviewer. A Highmark Physician Reviewer may contact the PCP or specialist to discuss the request or to obtain additional clinical information.
A decision is made after all of the clinical information has been reviewed.
At any time, the PCP or specialist may request a copy of the criteria/guidelines used in making medical/surgical decisions by calling Highmark at 1-800-421-4744. To request a copy of the criteria/guidelines used in making behavioral health decisions, call 1-800-258-9808.
All network providers are expected to notify their Highmark patients of both approval and denial-of-coverage decisions as soon as possible upon their office receiving notification of the decision from Highmark or a delegated entity of Highmark.
You know that many of your patients struggle with one or more health conditions that may slow them down, cause pain, and interfere with quality of life. Those conditions can take a toll on work, family, and social life.
You also know the good news: that even serious health conditions can be managed and that the need for emergency care and unnecessary hospitalization can be reduced.
Condition management programs are available to Highmark members who need help managing chronic health conditions, including:
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A Highmark Clinician — a member of Highmark's staff who is trained as a registered nurse or health care specialist who teams up with you, the doctor — can help your patients develop the skills they need to manage their conditions and improve their health and quality of life. Our condition management programs cover all aspects of dealing with a chronic condition, such as understanding a new diagnosis, taking the right medicine at the right time, managing symptoms, and changing habits and behaviors that affect overall health.
Our Clinicians provide patients with materials and resources designed to be supportive of your plan of care. There is no cost to the member for these programs.
So, if you have a patient with one or more of the conditions noted above (or any other health concerns), you can refer the patient to Blues On Call by asking him or her to call 1-888-BLUE-428 (1-888-258-3428).
Our members have certain rights and responsibilities that are a vital part of membership with a managed care or PPO plan. These rights and responsibilities are included in the member handbooks and are reviewed annually in the member newsletter.
We also make them available online for our network providers to help you maintain awareness and support your relationship with your Highmark patients. (On the Provider Resource Center, click on Education/Manuals. You'll find the Member Rights and Responsibilities in Chapter 3, Unit 2, of the Highmark Blue Shield Office Manual and in Chapter 3, Unit 3, of the Highmark Facility Manual.) A paper copy of the Member Rights and Responsibilities is available upon request.
Highmark provides you with an opportunity to discuss Utilization Management (UM) denial decisions with a clinical peer reviewer following notification of a denial determination. Clinical peer reviewers are licensed and board-certified physicians, licensed behavioral health care practitioners, and licensed pharmacists, and they are available to discuss review determinations during normal business hours.
Your call will be connected directly to the peer reviewer involved in the initial review determination, if he or she is available. If the original peer reviewer isn’t available when you call, another clinical peer will be made available to discuss the denial determination within one business day of your request. To request a peer-to-peer conversation, you may call the appropriate number listed in the chart below.
*IMPORTANT NOTE: The peer-to-peer review process is no longer available for Medicare Advantage members. See Chapter 3, Unit 6, of the Highmark Blue Shield Office Manual and Chapter 6, Unit 1, of the Highmark Facility Manual for details.
PRACTITIONER/ |
UM ISSUE |
TELEPHONE NUMBER |
Practitioners |
Med/Surg UM decisions |
1-866-634-6468 |
Behavioral health providers |
Behavioral health |
1-866-634-6468 |
Pharmacists |
Pharmacy services |
Telephone number identified on determination letter |
Practitioners |
Advanced radiology imaging |
Telephone number identified on determination letter |
Practitioners |
Radiation Therapy |
Telephone number identified on determination letter |
Practitioners |
Physical Medicine |
Telephone number identified on determination letter |
