Past Year: 2023
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.
July 19, 2024
Chapter 1, Unit 2: Online Resources & Contact Information
- In 1.2 Mailing Addresses, “Claims Filing Addresses” documents that were linked under the CLAIMS FILING ADDRESSES heading were removed. That information is now included in tables in that section.
- NOTE: The newly added tables include Federal Employee Program (FEP) addresses. For that reason, the FEP addresses were removed from 1.2 Contact Information, which now includes language referring providers to 1.2 Mailing Addresses.
Chapter 2, Unit 2: Medicare Advantage Products & Programs
- In 2.2 Highmark Medicare Advantage Products, the following changes were made:
- Separated the NENY Medicare Advantage PPO network from the Freedom Blue PPO network, which is in Delaware, Pennsylvania, and West Virginia.
- Replaced the Senior Blue HMO network with the NENY Freedom HMO network for Northeastern New York.
- Added the Together Blue HMO network in Western Pennsylvania.
- Corrected the name of Western New York’s WNY Medicare Advantage HMO.
- Corrected the coverage of WNY Forever Blue PPO to only cover Western New York’s service area.
Chapter 3, Unit 2: Professional Provider Credentialing
- In 3.2 Highmark Network Credentialing Policy, a link to Reimbursement Policy (RP)-068 was added to the ADVANCED PRACTICE PROVIDER (APP) ENUMERATION section.
Chapter 4, Unit 2: Behavioral Health Providers
- In 4.2 General Information, the Behavioral Health contact information, including both fax and phone numbers, was updated for all Highmark service regions.
Chapter 5, Unit 4: Behavioral Health
- In 5.4 Retrospective Review, the Retrospective Review mailing address for mental health and substance use disorder treatment was updated for Delaware, Pennsylvania, and West Virginia.
Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals
- In 5.5 Expedited Provider Appeal Process, the phone number to initiate an expedited provider appeal was updated for Delaware, Pennsylvania, and West Virginia.
- In 5.5 Standard Provider Appeal Process:
- The phone number to initiate a standard provider appeal was updated for Delaware, Pennsylvania, and West Virginia.
- The mailing address for Behavioral Health Services (all service areas) was updated for post-service appeals and Federal Employee Program (FEP) provider appeals.
Chapter 6, Unit 3: Facility (UB-04/8371) Billing
- In 6.3 Present on Admission/Adverse Events, a link to RP-036 was added to the REIMBURSEMENT POLICY RP-036 section.
Relinquishment of Washington County, Ohio
Highmark Blue Cross Blue Shield in West Virginia relinquished the Washington County, Ohio, service area. The change — which was requested by Highmark — was approved by the Blue Cross Blue Shield Association (BCBSA) in November 2023.
For this reason, references to Washington County, Ohio, were removed from the following areas of the manual:
- 1.1 About Highmark
- 1.2 Highmark Websites (PUBLIC WEBSITES section)
- 2.1 Introduction (HIGHMARK’S CORPORATE ENTITIES section)
- 3.1 Directing Care to Network Providers (LOCATING NETWORK PROVIDERS section)
July 1, 2024
Chapter 6, Unit 3: Facility (UB-04/8371) Billing
- In 6.3 Outpatient Services Prior To An Inpatient Stay, a link to Reimbursement Policy (RP)-039 was added to the REIMBURSEMENT POLICY RP-039 section.
Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips
- In 6.4 Modifiers:
- A link to RP-001 was added to the ASSISTANT AT SURGERY: MODIFIERS 80, 81, 82, & AS section.
- A link to RP-002 was added to the CO-SURGERY: MODIFIER 62 section.
- In 6.4 Anesthesia Reporting Tips, a link to RP-033 was added to the MEDICAL DIRECTION (SUPERVISION) OF ANESTHESIA REPORTING/PAYMENT* section.
- In 6.4 Reporting Mid-Level Provider Services for Medicare Advantage (PA and WV Only), links to RP-001, RP-010, and RP-068 were added to the REIMBURSEMENT FOR SERVICES PERFORMED BY MID-LEVEL PROVIDERS section.
June 28, 2024
Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, fax references related to prior authorization for West Virginia were removed from the Highmark Provider Manual.
June 20, 2024
Chapter 5, Unit 1: Care Management Overview
- In 5.1 High-Risk Maternity (NY Only), the following changes occurred:
- A link to the New York State Department of Health prenatal assessment form (which only applies to Highmark Blue Cross Blue Shield members in Western New York) was provided.
- The phone number for Interventions for High-Risk Patients was updated to 800-871-5531.
- The hyperlink for the Health Commerce System was updated.
- Under the LABORATORY REPORTING REQUIREMENTS section, language was updated to align with recent changes made to 5.1 Practice Guidelines and Standards of Care for HIV (NY Only).
- Additional minor wordsmithing and formatting changes were made.
Chapter 5, Unit 6: Quality Management
- In 5.6 Functional Areas and Their Responsibilities, the language was updated to reflect that the Senior Medical Director is solely responsible for administration and implementation of the Health Care Quality Improvement Program, as the position of Vice President Health Management has been eliminated.
June 14, 2024
Chapter 3, Unit 2: Professional Provider Credentialing
- In 3.2 Termination from the Networks, a MEMBER NOTIFICATION section was added to indicate that a provider’s patients (who are Highmark members) will automatically be notified via U.S. Mail when that provider is terminated from the Highmark provider network.
Chapter 3, Unit 3: Professional Provider Guidelines
- 3.3 How to Resign from Network Participation was updated to indicate that providers must use the electronic Request to Terminate a Contracted Network form if they decide to resign from the Highmark provider network. Other methods, including fax, have been eliminated. In addition, when providers decide to resign from the Highmark provider network, their patients — who are Highmark members — will be automatically notified via U.S. Mail.
Chapter 5, Unit 1: Care Management Overview
- In 5.1 Practice Guidelines and Standards of Care for HIV (NY Only), there were numerous updates, including:
- Lower threshold for recommending HIV testing: Providers should now adopt a lower threshold for recommending HIV testing, as many patients may not be comfortable disclosing risk factors.
- Updated resources: The manual now includes updated links and contact information for HIV testing resources, including the AIDS Institute NYSDOH Counseling and Testing Resources and the NYSDOH AIDS Institute Resource Directory.
- New HIV reporting requirements: Healthcare providers are now required to report any HIV diagnosis within one day and complete the Medical Provider HIV/AIDS and Partner/Contact Report Form within seven days.
- Improved laboratory reporting requirements: Laboratories are now required to report HIV-related test results with more detailed patient information to improve data quality and linkage to care.
- Updated reporting timeframe for suspected seroconversion: The timeframe for reporting suspected seroconversion has been updated from 14 days to seven days.
Chapter 5, Unit 2: Authorizations
- In 5.2 Authorization Guidelines, the VENDOR DELEGATION AND OVERSIGHT section was updated, as file audits are now conducted on a monthly, rather than a quarterly, basis.
- In 5.2 Emergency Services, the following addition was made to the EMERGENCY CARE DEFINED section:
- "Any condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act, including with respect to a pregnant woman who is having contractions — that there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child."
Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals
- In 5.5 Grievances and Appeals (NY Only), a few minor changes were made, including correcting a typo on the section title, “APPEALING AN UPHELD DENIAL (LEVEL II).”
May 30, 2024
Chapter 6, Unit 1: General Claim Submission Guidelines
- 6.1 Self-Funded Accounts, which had been specific to West Virginia, was updated to be applicable to all Highmark service regions.
May 29, 2024
Chapter 1, Unit 2: Online Resources & Contact Information
- In 1.2 Contact Information, the FEDERAL EMPLOYEE PROGRAM (FEP) section was updated to include physical addresses for FEP in all four states of Highmark’s footprint. This was done in the event that providers are unable to submit FEP claims electronically. In addition, hours were updated for the customer service phone lines for Delaware, Pennsylvania, and West Virginia.
May 15, 2024
Chapter 3, Unit 2: Professional Provider Credentialing
- In the ADMITTING AND CLINICAL PRIVILEGE REQUIREMENTS section of 3.2 Highmark Network Credentialing Policy, “Hospice & Palliative medicine” was added to the list of specialties for which the hospital clinical privilege requirement is waived.
- In the ADDITIONAL BEHAVIORAL HEALTH SPECIALTIES CRITERIA section of 3.2 Credentialing Requirements for Behavioral Health, “licensed” was added to the requirements for the specialty of Marriage and Family Therapist.
Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals
- The information in the following sections was updated to include Delaware as an applicable region:
- 5.5 Medicare Advantage: Provider Appealing on Own Behalf (DE, PA, and WV Only)
- 5.5 Medicare Advantage: Appeals on Behalf of a Member (DE, PA, and WV Only)
Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips
- In 6.4 Anesthesia Reporting Tips, the language was updated to align with Reimbursement Policy 033 (RP-033): Anesthesia Services. The Physical Status Units table was enhanced, while the section on Modifying Units was eliminated.
May 6, 2024
All references to naviHealth in the Provider Manual have been changed to Home & Community Care Transitions to reflect the company's name change. Home & Community Care Transitions is a third-party vendor used by Highmark for post-acute care services for Highmark's Medicare Advantage members in Pennsylvania and West Virginia.
April 26, 2024
Highmark finalized changes to the Provider Manual related to the provider portal transition from NaviNet and HEALTHeNET (NY) to Availity. NaviNet and HEALTHeNET (NY) access for providers ended on April 26, 2024.
April 19, 2024
Chapter 2, Unit 6: The BlueCard Program
- In 2.6 Itemized Bills Required for High-Dollar Host Claims, the amount considered a high-dollar claim was changed from “$100,000 or greater” to “$50,000 or greater.”
- In 2.6 NAIC Codes, changes were made to the PENNSYLVANIA NAIC CODE PROVIDER TYPE PRODUCTS table to align with information in Chapter 6, Unit 2: Electronic Claim Submission > 6.2 NAIC Codes. The table was updated to include the following information:
- For 54771W, the Northeastern region was added.
- For both 54771W and 54771, prefixes were added to these products:
- Medicare Advantage Security Blue HMO-POS (prefixes JOF, JOL)
- Together Blue Medicare HMO (prefix K9P)
- Medicare Advantage Community Blue Medicare HMO administered by Highmark Choice Company (prefixes ZPM, KHC)
- For 54771C, prefixes (ZPM, KHC) were added to Medicare Advantage Community Blue Medicare HMO administered by Highmark Choice Company.
- 54771S for Southeastern region facility type providers (UB-04/837I) was added.
- For 15460, this product was added:
- Medicare Advantage Complete Blue PPO (prefix C4K)
- Minor wordsmithing changes were made to both the 2.6 NAIC Codes and 6.2 NAIC Codes sections of the Highmark Provider Manual.
Chapter 3, Unit 2: Professional Provider Credentialing
- In 3.2 Highmark Network Credentialing Policy, the ADVANCED PRACTICE PROVIDER (APP) ENUMERATION section was updated to point providers to Reimbursement Policy 068 (RP-068): Mid-Level Practitioners and Advanced Practice Providers for more information instead of Reimbursement Policy 010 (RP-010).
Chapter 5, Unit 4: Behavioral Health
- In 5.4 Retrospective Review, the address for New York’s Utilization Management Appeals Unit was updated in the table in the MAILING ADDRESS section.
Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals
- In 5.5 Standard Provider Appeal Process, the address for New York’s Utilization Management Appeals Unit was updated in the table in the MAILING ADDRESSES section.
- In 5.5 Filing an Appeal on Behalf of the Member, the address for New York’s Utilization Management Appeals Unit was updated in the table in the WRITTEN REQUESTS section.
Chapter 5, Unit 6: Quality Management
- In 5.6 Quality Management Program Overview, the ORGANIZATIONAL STRUCTURE section was updated to reflect current functional areas of the Quality Management Program. In addition, the OVERALL OBJECTIVES OF THE QUALITY PROGRAM section was updated with appropriate language.
- In 5.6 Highmark Quality Program Committees, the CARE MANAGEMENT AND QUALITY COMMITTEE (CMQC) section was updated to add clarification that the committee represents “western and northeastern” New York.
- In 5.6 Functional Areas and Their Responsibilities, the CLINICAL SERVICES – QUALITY section was updated with current department names and responsibilities for each area.
- In 5.6 Practitioner Office/Facility Site Quality and Medical/Treatment Record Evaluations, “Representatives” replaced “Management Analysts” in the following sentence in the PRACTICE SITE RESOURCES section: The Practice Site Resources materials are used by Highmark Clinical Quality Representatives to educate the practitioner office designees when performing office site and medical record documentation reviews.
Chapter 6, Unit 2: Electronic Claim Submission
- In 6.2 NAIC Codes, minor wordsmithing changes were made to align with information in Chapter 2, Unit 6: The BlueCard Program > 2.6 NAIC Codes.
February 21, 2024
Chapter 2, Unit 2: Medicare Advantage Products & Programs
- In 2.2 House Call Program, information regarding the House Call program was updated, including:
- The program is available to members in Highmark’s Affordable Care Act and Medicaid lines of business — not just Medicare Advantage.
- The participating vendors were updated.
Chapter 2, Unit 6: The BlueCard Program
- In 2.6 NAIC Codes, New York state information was added, including NAIC Code 55204, as well as claim submission procedures for Empire/Anthem and Excellus members when treated by Highmark providers.
Chapter 6, Unit 1: General Claim Submission Guidelines
- In 6.1 Timely Filing Requirements, the NEW YORK TIMELY FILING POLICY section was updated. Language was clarified to emphasize that all initial claims (original bill type) must be submitted within 365 days, including weekends, from the date of service/discharge. In addition, all corrected claim submissions (bill type ending in 7) must be received within 365 days from the last date of processing of the original claim submission, including weekends.
Chapter 6, Unit 2: Electronic Claim Submission
- In 6.2 Submitting Claims (NY Only), the CLAIM ADJUSTMENT POLICY and EXCLUSIONS TO THIS POLICY sections were removed to align New York with Highmark’s overall claim adjustment policy.
Chapter 6, Unit 8: Payment Review
- The following New York-related updates were made:
- In 6.8 Financial Investigations and Provider Review (FIPR), a second New York fraud hotline number was added.
- In 6.8 Payment Review Process, New York was added as part of the participating, preferred, and managed care networks Highmark is required to monitor.
- In 6.8 Retroactive Denials and Overpayments, a NEW YORK STATE INSURANCE LAW section and a PROVIDER RECOVERY PROCESS section for New York were added.
- In 6.8 Post-Payment Dispute Resolution Process – Appeals and External Reviews:
- The APPEAL RIGHTS IN NEW YORK section was updated.
- Information on New York member appeal rights was removed, as similar content is available in Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals.
January 29, 2024
Chapter 2, Unit 5: Telemedicine Services
- Throughout this unit, all references to Doctor on Demand were removed, as the vendor’s relationship with Highmark ended on December 31, 2023. Other telemedicine services provided by Amwell — along with the applicable member benefit — were added to this section, including:
- Urgent Care within the Telemedicine Service Benefit
- Behavioral Health within Outpatient Mental Health
- Primary Care under PCP/Physician Office Visit
- Dermatology under Specialist Office Visit
- Women’s Health
- Medical Care under Telemedicine Service
- Therapy under Outpatient Mental Health
- Lactation under Preventive Adult Care
Chapter 3, Unit 1: Network Participation Overview
- In 3.1 Introduction to Network Participation, the Additional Providers Eligible in NY section was updated to add the following:
- Effective January 1, 2024, Licensed Mental Health Counselors (LMHC) are also eligible in Medicaid and Medicare Advantage networks.
- Effective January 1, 2024, Psychoanalysts with a Psychoanalyst license are eligible in all commercial networks.
- In 3.1 PROMISe Enrollment Required for Pennsylvania CHIP, the Your PROMISe ID Is Automatically Added to Highmark’s Provider File section was revised to reflect that practitioners no longer need to update their PROMISe ID with Highmark, as PROMISe ID updates are submitted electronically to Highmark by the Pennsylvania Department of Human Services.
Chapter 3, Unit 2: Professional Provider Credentialing
- In 3.2 Highmark Network Credentialing Policy, the following changes were made:
- Types of Professional Providers Credentialed section:
- Licensed Dietitian – Nutritionists are not eligible for NY Medicaid.
- Licensed Psychoanalysts are recognized by Highmark as a credentialed allied health professional in New York only.
- Under 24/7 Availability Requirements, the following specialties were added as exempt:
- Certified Diabetic Educators
- Massage therapists
- Psychologists who perform neuropsychological testing or psychological evaluations only
- Read-only practitioners
- Availability for Urgent and Routine Care section:
- Requirement for a minimum of 20 office hours a week — when not joining an existing group network — only applies to networks in Pennsylvania.
- PCP practices in Pennsylvania not meeting this requirement will be subject to an on-site review every three years and will be noted in the provider directory as having limited hours.
- The Time Frame – Highmark West Virginia Participating Practitioners section was removed, as it is no longer a requirement for West Virginia.
- A Time Frame – Massachusetts section was added.
- In 3.2 The Credentialing Process, the following change was made:
- Under Steps in The Initial Credentialing Process, Step 4 was updated to remove the following from the list of what the Credentialing Department will review applications for:
- Ability to enroll new members.
- Office hour availability of at least 20 hours/week (PCP)
- In 3.2 Credentialing Requirements for Behavioral Health, the following changes were made:
- A Licensed Psychoanalyst section was added. Effective January 1, 2024, psychoanalysts must be licensed as a psychoanalyst in New York.
- Under Additional Behavioral Health Specialties Criteria, “Behavioral Analysts/Behavioral specialists licensed or certified per state regulation” was added.
- In 3.2 Practitioner Quality and Board Certification, under Highmark Recognized Boards for Certification, National Board of Physicians and Surgeons (NBPAS) was added.