Highmark Provider Manual Changes

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.

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.