New DME Fee Schedule, MCG Transition, and More

New DME Fee Schedule

Highmark Blue Cross Blue Shield West Virginia routinely reviews its fee schedule reimbursement rates and adjusts, as necessary, to maintain appropriate and reasonable payments to providers. Reimbursement changes are made to reflect current factors and trends in the marketplace. As a result of this process, effective April 1, 2023, Highmark Blue Cross Blue Shield West Virginia will adjust its Durable Medical Equipment (DME) fee schedule for the commercial lines of business. For more information, go here .


Emergency Department Claim Audits

Effective May 1, 2023, Highmark will begin auditing all outpatient Emergency Department facility claims to ensure the correct procedure codes are being billed. This may result in a different reimbursement than expected, with Highmark updating the claim to correct the procedure code.

These audits are designed to determine the appropriate and fair level of facility reimbursement for emergency department services based on the Centers for Medicare and Medicaid Services (CMS) criteria to determine the appropriate procedure code. To read the Special Bulletin, go here .


Submitting Fractional Numbers for Ambulance Mileage

Effective April 14, 2023, for ambulance services claims, providers must submit the exact fractional mileage used. This includes wheelchair van, stretcher van, ground, and air ambulance transport claims submitted for commercial and Medicare Advantage members. To learn more, go here .


Follow-Up After Emergency Department Visit for Mental Illness

Highmark is committed to improving follow-up care for members with behavioral health needs. As a result, Highmark added a new flag to our Daily Emergency Room (ER) Provider Report on February 13, 2023. This flag will alert providers when a member has been seen in an emergency room with a diagnosis qualifying for the HEDIS® metric Follow-Up After Emergency Department Visit for Mental Illness (FUM).

To learn more, log on to NaviNet® and click on Resource Center from the blue left-hand menu. Once you are redirected to the Provider Resource Center, go to the Plan Central Library which can be found under NEWSLETTERS/NOTICES on the left-hand menu.


Transition to MCG

Effective February 13, 2023, Highmark incorporated MCG Health clinical guidelines into our criteria of clinical decision support, replacing Change Healthcare (InterQual). This change is being made to align the clinical review processes and platforms for Highmark health plans. To learn more, go here .


Telemedicine and Telehealth Update

Highmark is changing Reimbursement Policy-046: Telemedicine and Telehealth Services (RP-046) to again allow reimbursement for the following codes: 99446, 99447, 99448, and 99449. This update is for all commercial lines of business effective February 20, 2023. For more information, go here .

 

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