Below is a timeline of changes made to the Highmark Provider Manual. They are organized by date the changes were implemented, with the most recent changes at the top of the page.
Always refer to the entire Highmark Provider Manual for complete guidance on policies and procedures for all providers participating in Highmark’s networks.
September 21, 2023
Chapter 1, Unit 4: Highmark Member Information
- In the 1.4 Confidentiality of Member Information section, the following language regarding robocalls to our call centers was added: "Highmark Inc. and its affiliated companies do not release information to artificial intelligence agencies. We will be glad to provide the information needed to the appropriate human stakeholders. Please have a human use our self-service tools available at highmark.com, through our provider portal, or call Customer Service for any information needed."
Chapter 6, Unit 1: General Claim Submission Guidelines
- In the 6.1 Top Billing Errors – And How to Avoid Them section, minor changes were made to the table under COMMON CLAIMS REPORTING ERRORS. Those changes include spelling out acronyms and updating the years used in examples.
September 5, 2023
Chapter 6, Unit 2: Electronic Claim Submission
- In the 6.2 NAIC Codes section under NEW YORK, clarifying language was added for claims submitted on behalf of Empire/Anthem members who are seen in the following counties: Albany, Clinton, Columbia, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington. These counties comprise the 13 counties of the Highmark Blue Shield of Northeastern New York service region.
August 24, 2023
Chapter 2, Unit 6: The BlueCard Program
- In the 2.6 NAIC Codes section, the PENNSYLVANIA NAIC CODE PROVIDER TYPE PRODUCTS table was updated. Prefixes were added to the following products for facility and other providers in Central and Western Pennsylvania:
- Medicare Advantage Security Blue HMO-POS (prefixes JOF, JOL)
- Medicare Advantage Community Blue Medicare HMO (prefixes ZPM, KHC)
- Together Blue Medicare HMO administered by Highmark Choice Company (prefix K9P)
Chapter 3, Unit 2: Professional Provider Credentialing
- In the 3.2 Highmark Network Credentialing Policy section, language under 24/7 AVAILABILITY REQUIREMENTS was updated to reflect that a referral to a crisis line/center is acceptable as long as the provider or his/her designee can be reached.
- In the 3.2 Credentialing Requirements For Facility-Based Providers section under FACILITY-BASED PRACTITIONER CREDENTIALING POLICY, updates were made to the credentialing policy for facility-based practitioners and include the following changes:
- In-Network Credentialing: The following types of facility providers must be currently credentialed by an in-network skilled nursing facility, ambulatory surgery center, inpatient hospital, and/or inpatient freestanding facility setting:
- Anesthesiologists
- Emergency medicine specialists
- Oral maxillofacial pathologists
- Oral maxillofacial radiologists
- Pathologists
- Radiologists
- Out-of-Network: To provide medical services to members outside of a network-participating facility, practitioners will be required to complete the initial credentialing and contracting processes.
Chapter 3, Unit 4: Organizational Provider Participation (Facility/Ancillary)
- In the 3.4 Urgent Care Centers/Medical Aid Units section, language under BILLING GUIDELINES was updated to reflect that Federal Employee Program members do not have coverage for code S9088.
Chapter 6, Unit 2: Electronic Claim Submission
- In the 6.2 NAIC Codes section:
- The PENNSYLVANIA table was updated. Prefixes were added to the following products for facility and other providers in Central Region and Western and Northeastern Regions:
- Medicare Advantage Security Blue HMO- POS (prefixes JOF, JOL)
- Medicare Advantage Community Blue Medicare HMO (prefixes ZPM, KHC)
- Together Blue Medicare HMO administered by Highmark Choice Company (prefix K9P)
- The NEW YORK table was updated. Plan codes were eliminated from the table. The remaining code is NAIC Code 55204. Language was clarified for claims submitted on behalf of Excellus members who live in the following four counties that were specified in this update: Clinton, Essex, Fulton, and Montgomery.
July 26, 2023
Chapter 5, Unit 1: Care Management Overview
- In the 5.1 Introduction to Care Management section, “Wellness” replaced “Health Promotion (except in New York)” in a bulleted list of core services.
- In the 5.1 High-Risk Maternity (NY Only) section:
- Under BENEFITS FOR PHYSICIANS, MOTHERS, AND THEIR BABIES, a link to the Preventive Health Guidelines page of the Provider Resource Center was added. There, the High-Risk Maternity clinical practice guidelines are included in the Prenatal/Perinatal Care Preventive Health Guidelines.
- Under POSTPARTUM VISIT COMPONENTS, links for supporting documentation were updated.
- In the 5.1 Practice Guidelines and Standards of Care for HIV (NY Only) section:
- Under AIDS INSTITUTE NYSDOH COUNSELING AND TESTING RESOURCES, the phone number for HIV Counseling was updated.
- Under PREGNANT WOMEN AND EXPOSED INFANTS LOST-TO-CARE REQUIRE IMMEDIATE ACTION FOR RE-ENGAGEMENT, the phone number for the New York State Department of Health Perinatal HIV Prevention Program was updated.
Chapter 5, Unit 2: Authorizations
- In the 5.2 Authorization Request Process section:
- Under HOME HEALTH AUTHORIZATION REQUESTS, the language was updated to reflect that authorization procedures for Delaware, Pennsylvania, and West Virginia are the same for each region. Previous language gave the appearance that there were different regional procedures.
- Under TELEPHONE REQUESTS, the contact information was updated. Professional providers should use the phone numbers for the appropriate Medicare Advantage program.
Chapter 5, Unit 6: Quality Management
- In the 5.6 Functional Areas and Their Responsibilities section, the committee list under QI Committee Structure (for providers in New York) was updated to include Highmark Inc./Highmark NY Utilization Management Master Service Agreement (MSA) Joint Oversight, and Network Quality and Credentials Committee.
- In the 5.6 Case Review Process for Quality Concerns section, language under IMPORTANT! (for providers in New York) was updated to: “Members are able to make clinical quality of care complaints to the health plan.”
- In the 5.6 Clinical Quality section under CONDITION MANAGEMENT PROGRAM, HIV/AIDS was added to the list of chronic conditions for which members are eligible to receive health coaching.
July 20, 2023
Chapter 4, Unit 1: PCPs and Specialists
- The 4.1 PCP And Medical Specialist Accessibility Expectations section was updated under ACCESSIBILITY EXPECTATIONS FOR PROVIDERS. For Urgent Care Appointments, the Performance Standard was changed from “Office visit within 1 day (24 hours)” to “Immediate response” in the PCP AND MEDICAL SPECIALIST ACCESSIBILITY EXPECTATIONS table.
June 23, 2023
Chapter 4, Unit 2: Behavioral Health Providers
- The 4.2 General Information section was updated under CONTACT INFORMATION. The contact information for Highmark Behavioral Health (BH) Services was updated to include a fax number for Delaware (DE), Pennsylvania (PA), and West Virginia (WV). In addition, Highmark BH Services no longer offers Sunday hours of operations.
Chapter 5, Unit 4: Behavioral Health
- The 5.4 General Information section was updated under CONTACT INFORMATION. The contact information for Highmark Behavioral Health (BH) Services was updated to include a fax number for Delaware (DE), Pennsylvania (PA), and West Virginia (WV). In addition, Highmark BH Services no longer offers Sunday hours of operations.
- The 5.4 Services Requiring Authorization section was updated under INPATIENT SERVICES. The bullet point for inpatient rehabilitation was updated to include "mental health treatment."
- The 5.4 Authorization Requests section was updated under NAVINET® AUTHORIZATION REQUEST SUBMISSION REQUIRED (applicable to providers in DE, PA, and WV) to include the following language: "However, if NaviNet is unavailable or the facility is not NaviNet-enabled, authorization reviews can be initiated by calling Highmark Behavioral Health Services at 1-800-258-9808 or faxing 1-877-650-6112."
Chapter 6, Unit 2: Electronic Claim Submission
- The 6.2 Submitting Claims (NY Only) section was updated under CLAIM ADJUSTMENT POLICY. The policy for New York was corrected to reflect that providers have 365 days, rather than 180 days, to file a claim adjustment request. This policy was implemented on January 1, 2022.
June 7, 2023
The section on Additional Diagnostic Code Reporting (New York Only) of Chapter 6, Unit 1 (General Claim Submission Guidelines) was updated to include a qualifying statement within the subsection on Sleep Studies noting that for Chemotherapy, Transfusion, Cast Room, Infusion Therapy and Treatment Rooms - the service could pay up to $50 per day for a room charge.
This qualifying statement was in the Provider Manual on the HealthNow provider websites, but was inadvertently omitted when transitioned to the Highmark Provider Resource Center websites.
May 24, 2023
The section on High-Risk Maternity - NY Only of Chapter 5, Unit 1 (Care Management Overview) was updated to include additional guidance under Interventions for High-Risk Patients. The following language was added: "After a total of no more than two (2) missed prenatal or one post-partum visit by the member, providers can call for Case Management assistance to request active member outreach at 877-878-8785 Monday through Friday 8 a.m. to 5 p.m. EST."
May 23, 2023
The new web-based Highmark Provider Manual was published on May 23, 2023.
Last updated on 9/21/2023 9:53:01 AM