Welcome Highmark Blue Shield Providers of Southeastern Pennsylvania

Highmark Blue Shield welcomes newly contracted providers in Southeastern Pennsylvania. To help you get acquainted with working together, we offer tools and resources through our Provider Resource Center (PRC). The Highmark PRC is the central location for helpful information such as:

• The Highmark Provider Manual
• Forms
• Important announcements and updates
• Medical, reimbursement, and pharmacy policies
• Provider newsletters
• Availity Essentials

We encourage you to become familiar with this site and its resources.

JOIN OUR MEDICARE ADVANTAGE NETWORK

If you are eligible to participate in the Highmark SEPA Medicare Advantage (MA) network, you should have received an updated contract or other outreach via email from PIMContracts@highmark.com notifying you that you will be added to the SEPA MA network effective January 1, 2025.

We encourage you to sign and return your contract as soon as possible since you will not be added to the MA network until we receive the signed document.

After January 1, 2025, you must be contracted with us directly to be in-network for all Highmark MA members and avoid disruption for your patients and your practice.

If you did not receive a contract via email, or cannot find the email and would like another contract sent to you, please contact us at  SEPAContractingQuestions@highmark.com or 844-945-5525.

• Highmark SEPA Medicare Advantage Network Frequently Asked Questions

PRC RESOURCES

Provider Manual

The Highmark Provider Manual contains information, policies, and procedures for participating medical providers. This manual is designed to be your primary reference guide for working with us. You can access the manual anytime through the Quicklinks bar on the top of the webpage.

Medical Policy Search / Medical Policy Update

Highmark’s medical policy guidelines are available through the Medical Policy Search which can be accessed on the Quicklinks bar. You can search by keyword, procedure code, or medical policy number. Medical Policy Update is a monthly newsletter that provides information about upcoming medical policy and claims administration updates. You can receive these updates by signing up for eSubscribe from the PRC homepage.

Pharmacy Policy Search / Formulary Updates

Pharmacy policies are intended to reflect Highmark's reimbursement and coverage guidelines. You can access them by clicking Pharmacy Policy Search in the Quicklinks bar. You can search by keyword or one of the following categories:

• Formulary
• Managed Rx Coverage
• Prior Authorization
• Quantity Level Limits
• Step Therapy

The Highmark Drug Formulary is a list of FDA-approved prescription drug medications reviewed by our Pharmacy and Therapeutics (P&T) Committee. The formularies and pharmaceutical management procedures are updated on a bi-monthly basis. Additional information on drug formularies and updates can be found on the Formulary Information page under PHARMACY PROGRAM/FORMULARIES on the sidebar menu.

Procedures Requiring Prior Authorization

Highmark requires authorization of certain services, procedures, and/or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) prior to performing the procedure or service. You can review which services and procedures require authorization by clicking on Requiring Authorization in the Quicklinks bar.

Reimbursement Policy

Highmark Blue Shield issues new or updated reimbursement policies regularly. You can check the Reimbursement Policy page under CLAIMS, PAYMENT & REIMBURSEMENT for policy updates. You can visit the Provider News page on the PRC as well as eSubscribe to Provider News to get these updates and announcements emailed to you on a monthly basis.

PROVIDER COMMUNICATIONS

Highmark is committed to keeping you informed by providing timely and pertinent information about our policies and programs.

• Provider News is Highmark’s monthly newsletter – posted to the PRC and sent via email -- for our network health care professionals, facilities, and their office staff. Provider News contains valuable news, information, tips, and reminders.

• Our eSubscribe email notification feature brings the latest Provider News and other Highmark information directly to your inbox ensuring you don’t miss important updates and changes. You can sign up for the eSubscribe distribution list here.

• Special Bulletins are posted to the main page of the PRC for easy access. We also post proprietary messages in our provider portal which can be accessed by logging into your provider account.

Recent SEPA-Specific Provider Communications:

• New NAIC Code for SEPA Region Facility Claims Effective January 1, 2024 (November 13, 2023)
• BlueCard Changes for Southeastern PA (September 25, 2023)

AVAILITY

Availity^® is a multi-payer platform that supports payer-provider transactions necessary to manage care for members. Providers in Southeastern Pennsylvania will use Availity to:

• Verify patient eligibility and benefits
• Check claim status
• Submit prior authorization requests
• Access Highmark-specific resources through a dedicated payer space

You may already use Availity to interact with other payers. You can begin using Availity for Highmark Blue Shield starting January 1, 2024. If you are already registered with Availity, you do not need to re-register.

If you are not registered with Availity, your practice can begin enrolling by October 22, 2023. For more information about registering with Availity, go to the Register and Get Started with Availity Essentials webpage.

Additional information about Availity can be found on the PRC Availity webpage and our Availity Frequently Asked Questions page.