Notifications for Providers

Several times annually, Highmark notifies providers of important policies and guidelines. The following notification is for your information and reference.

ambulanceHighmark Reimbursement Policy RP-054, Ambulance Services, Now Applicable to Highmark West Virginia

Highmark Reimbursement Policy Bulletin RP-054, Ambulance Services, was developed to provide reimbursement direction for medically necessary ground ambulance services provided for Highmark members. This policy is now applicable to Highmark West Virginia commercial products effective February 1, 2020. It applies to both professional (1500/837P) and facility (UB-04/837I) claims.
 
To access Highmark Reimbursement Policy Bulletin RP-054 on the Provider Resource Center, select CLAIMS, PAYMENT & REIMBURSEMENT, and then click on Reimbursement Policy.  

Preventive Health Guidelines Available Online

Highmark and participating network physicians annually review and update the Preventive Health 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 Preventive Health Guidelines.

The Preventive Health Guidelines include:

  • Adult (under and over 65)
  • Pediatrics
  • Prenatal/perinatal

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
Director, Accreditation and Compliance
Fifth Avenue Place
120 Fifth Avenue, Suite P4425
Pittsburgh, PA 15222

Appropriate Utilization Decision Making

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 review decision-makers to encourage denials of coverage.

Request for Criteria

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.

Patient Notification of Approvals, Denials

All network providers are expected to notify their patients who are Highmark members 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.

Member Rights and Responsibilities

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 patients who are Highmark members.

(On the Provider Resource Center, click on Education/Manuals. You'll find the Member Rights and Responsibilities in Chapter 1, Unit 5, of the Highmark Provider Manual.) A paper copy of the Member Rights and Responsibilities is available upon request.

Case Management Referral

You can now submit automated referrals for Clinical Care and Wellness (CC&W) case management programs via NaviNet. This feature will help to:

  • Ensure that patients with chronic conditions and complex medical needs are connected with the right clinical support for their needs. 
  • Simplify and expedite the overall case management referral process
  • Reduce administrative burden 

To access this feature:

  • Log into NaviNet and and access Plan Central.
  • Click the Case Management Referral and Inquiry link under Workflows for this Plan to go to the Clinical Care & Wellness page.
  • Click the Create New Referral button under Submit New Referral to CC&W
  • Follow the steps to create and submit the referral.

We also want to remind you that the Highmark Member Clinical Programs and Services catalog (complete with useful information and helpful resources) is available to further your understanding of the full range of programs and services available to Highmark members in all service areas for all lines of business. 
 
We encourage you to review this catalog to help you identify members who can benefit from the programs and services we offer.
 
To access the Highmark Member Clinical Programs and Services catalog on the Provider Resource Center:

  • Click EDUCATION/MANUALS 
  • Click Clinical Programs and Services for Highmark Members
  • Click the link to the Catalog Reference Guide

Peer-to-Peer Conversations: Availability of Physicians, Behavioral Health Practitioners, and Pharmacist Reviewers*

Highmark provides you with an opportunity to discuss utilization review 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 5, Units 3 and 5, of the Highmark Provider Manual for details.

PRACTITIONER/
ORDERING PROVIDER

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

 

Provider Accessibility Expectations

To stay healthy, our members must be able to see their physicians when needed. To support this goal, Highmark’s expectations for accessibility of primary care physicians (PCPs), medical specialists, obstetricians, and behavioral health providers are outlined below.

The standards set forth specific time frames in which network providers should respond to member needs based on symptoms.
Physicians are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

PCP and Medical Specialist Accessibility Expectations

Patient’s Need:

Performance Standard:

Emergency/life-threatening care

  • Sudden, life-threatening symptom(s) or condition requiring immediate medical treatment (e.g., chest pain, shortness of breath)

Immediate response

Urgent-care appointments

  • An urgently needed service is a medical condition that requires rapid clinical intervention as a result of an unforeseen illness, injury, or condition (e.g., high fever, persistent vomiting/diarrhea)

Office visit within 1 day (24 hours)

Regular and routine care appointments

  • Non-urgent but in need of attention appointment (e.g., headache, cold, cough, rash, joint/muscle pain)
  • Routine wellness appointments (e.g., asymptomatic/preventive care, well child/patient exams, physical exams)

Pennsylvania and West Virginia:
• Within 2-7 days (Non-urgent)
• Within 30 days (Routine wellness)

Delaware:
Office visit within 3 weeks of member request

After-hours care

  • Access to practitioners after the practice’s regular business hours

Acceptable process in place to respond
24 hours per day, 7 days a week to
member issues (answering service that
pages the practitioner or answering
machine message telling caller how to
reach the practitioner after hours)

In-office waiting times

  • Practitioners are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

Within 15 minutes

 

Maternity Care Accessibility Expectations (Obstetrics)

Patient’s Need:

Performance Standard:

Maternity Emergency

Immediate response

Maternity 1st Trimester

Within 3 weeks of first request

Maternity 2nd Trimester

Within 7 calendar days of first request

Maternity 3rd Trimester

Within 3 calendar days of first request

Maternity High Risk

Within 3 days of identification of high risk

 

Behavioral Health Provider Accessibility Expectations

Patient’s Need:

Performance Standard:

Care for a life-threatening emergency

  • Immediate intervention is required to prevent death or serious harm to patient or others

Immediate response

Care for a non-life-threatening emergency

  • Rapid intervention is required to prevent acute deterioration of the patient’s clinical state that compromises patient safety

Care within 6 hours

Urgent care

  • Timely evaluation is needed to prevent deterioration of patient condition

Office visit within 48 hours

Routine office visit

  • Patient’s condition is considered to be stable

Pennsylvania and West Virginia:
Office visit within 10 business days

Delaware:
Office visit within 7 calendar days

After-hours care

  • Access to providers after the practice’s regular business hours

Acceptable process in place to respond
24 hours per day, 7 days a week to
member issues (answering service that
pages the provider or answering
machine message telling caller how to
reach the provider after hours)

In-office waiting times

  • Providers are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

Within 15 minutes

 

 

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