CLINICAL/OPERATIONAL UPDATES

PAYMENTS RELATED TO MEDICARE SEQUESTRATION

Highmark has aligned with CMS to extend temporary payment increases related to Medicare sequestration through March 31, 2021. Read ebulletin, HIGHMARK TEMPORARILY INCREASING PAYMENTS RELATED TO MEDICARE SEQUESTRATION for detailed information.

Medicare Sequestration Payments

 

AUTHORIZATION EXTENSIONS

Highmark has extended the timeframe for new prior authorization requests for ancillary/DME and inpatient planned surgeries through March 31, 2021. Read ebulletin, EXTENDED: OPEN AUTHORIZATIONS for detailed information.

 

 

PRESCRIBING MEDICATIONS DURING THE COVID-19 PANDEMIC

Prescribing Medications

 

PLACE OF SERVICE CHANGES FOR AUTHORIZED SERVICES

Place of Service Changes

 

 

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

 

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 1/4/2021

 

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