Short Takes: First Priority Health, MCG Transition, and More

First Priority Health

Highmark Blue Cross Blue Shield members within the First Priority Health (FPH) HMO network may now request outpatient laboratory and radiology services from any participating facility, no matter the location. When requesting one of these services, providers must submit a script and authorization. Per this change, the FPH Outpatient Laboratory program in Luzerne and Lackawanna counties and the Outpatient Radiology program in Luzerne County (excluding Berwick and Hazleton areas) was eliminated on January 1, 2023. To read more, go here .

Reprocessing Effort for July BlueCard Plan Claims Continues

As previously communicated, a number of BlueCard claims submitted to Highmark between July 1 and July 19, 2022, were incorrectly processed as out-of-network. Highmark continues to work with the Blue Plans who served as the Home Plans to reprocess these claims. Due to the volume of claims impacted, this has taken longer than anticipated. We believe that we will complete this process for most of the claims by the end of March, but it may take until the end of the second quarter to ensure we have addressed all the impacted claims. To read the entire Special Bulletin, go here .

Emergency Department Claim Audits

Effective May 1, 2023, Highmark will begin auditing all outpatient Emergency Department facility claims to ensure the correct procedure codes are being billed. This may result in a different reimbursement than expected, with Highmark updating the claim to correct the procedure code.

These audits are designed to determine the appropriate and fair level of facility reimbursement for emergency department services based on the Centers for Medicare and Medicaid Services (CMS) criteria to determine the appropriate procedure code. To read the Special Bulletin, go here .

Submitting Fractional Numbers for Ambulance Mileage

Effective April 14, 2023, for ambulance services claims, providers must submit the exact fractional mileage used. This includes wheelchair van, stretcher van, ground, and air ambulance transport claims submitted for commercial and Medicare Advantage members. To learn more, go here .

Follow-Up After Emergency Department Visit for Mental Illness

Highmark is committed to improving follow-up care for members with behavioral health needs. As a result, Highmark added a new flag to our Daily Emergency Room (ER) Provider Report on February 13, 2023. This flag will alert providers when a member has been seen in an emergency room with a diagnosis qualifying for the HEDIS® metric Follow-Up After Emergency Department Visit for Mental Illness (FUM).

To learn more, log on to NaviNet® and click on Resource Center from the blue left-hand menu. Once you are redirected to the Provider Resource Center, go to the Plan Central Library which can be found under NEWSLETTERS/NOTICES on the left-hand menu.

Transition to MCG

Effective February 13, 2023, Highmark incorporated MCG Health clinical guidelines into our criteria of clinical decision support, replacing Change Healthcare (InterQual). This change is being made to align the clinical review processes and platforms for Highmark health plans. To learn more, go here .

Telemedicine and Telehealth Update

Highmark is changing Reimbursement Policy-046: Telemedicine and Telehealth Services (RP-046) to again allow reimbursement for the following codes: 99446, 99447, 99448, and 99449. This update is for all commercial lines of business effective February 20, 2023. For more information, go here .