CLINICAL/OPERATIONAL UPDATES

PLACE OF SERVICE CHANGES FOR AUTHORIZED SERVICES

Place of Service Changes

 

PAYMENTS RELATED TO MEDICARE SEQUESTRATION

Medicare Sequestration Payments

 

CHANGES TO REIMBURSEMENT POLICY 041 (SERVICES THAT ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT)

Changes to Reimbursement Policy 041

 

TIMELY FILING POLICY

Due to the COVID-19 public health emergency, Highmark is modifying our timely filing policy temporarily for claim submissions from participating providers.

All in-network providers will have 365 days to submit claims with dates of service beginning February 1, 2020, through June 30, 2020.

 

QUARTERLY DIRECTORY DATA VALIDATION

Important: Quarterly Directory Data Validation Process Change

 

IMPORTANT: MEDICAL POLICY CHANGES TO ADDRESS EASY ACCESS TO NECESSARY SUPPLIES DURING COVID-19 OUTBREAK

Policy Changes to Address Easy Access to Necessary Supplies During COVID-19 Outbreak


EXPEDITED CREDENTIALING OF PROVIDERS DUE TO COVID-19

Expedited Credentialing of Providers Due To COVID-19

 

AUTHORIZATION EXTENSIONS

To help ease administrative burden during current circumstances, Highmark has extended the timeframe for some procedure authorizations in order to avoid the need for providers to submit a second authorization request.

 

Procedure Effective Date Ext. Timeframe Notes
Non-urgent surgeries March 18, 2020 180 days
Ancillary/DME March 18, 2020 180 days
Elective outpatient
planned surgeries
March 18, 2020 180 days
Elective inpatient
planned surgeries

March 26, 2020

180 days Providers must contact Highmark with the new date of service for these procedures. Highmark will update the authorization to
reflect the new date of service if the procedure is performed within 180 days
of the initial authorization. A new medical necessity review will be required only
if the new date of service is more than 180 days from the initial authorization.
All authorizations for services submitted via eviCore March 1, 2020 180 days
Physical Medicine
Program (submitted
via WholeHealth
Networks, Inc., a
subsidiary of Tivity
Health Support, LLC.)
February 1, 2020 120 days from
initial authorization
The extension is effective on all finalized authorizations with a start date of February 1, 2020 and beyond until
further notice. 

 

POST-PAY CLAIM AUDITS

Highmark’s Financial Investigation and Provider Review (FIPR) team is mindful of the current COVID- 19 pandemic and strain on the administrative resources available to respond to post-pay claim audits. Effective immediately, the timeframe in which to respond to medical record requests or to request an appeal for a claim audit finding will be extended from 30 days to 90 days. This timeframe extension will apply to all inflight professional and facility post-pay claim audits starting on or before May 31, 2020 managed either by FIPR or one of FIPR’s external audit partners (e.g. CGI, Equian or Trend Health Partners).

 

PRESCRIPTION MEDICATION REFILLS

We are increasing access to prescription medications by waiving early medication refill limits on 30-day prescriptions and encouraging members to use 90-day mail order benefits when available.

 

ALTERNATE HEDIS CHART SUBMISSION GUIDELINES

HEDIS Chart Review and Alternate Submission Guidelines Regarding the Coronavirus 2019 (COVID-19)

 

PEER-TO-PEER REVIEW TIME FRAME

Peer-to-peer review time frame increased to 180 days

Last updated on 5/21/2020

 

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