Notifications for Providers
Several times a year, Highmark notifies providers of important policies and guidelines. The following notification is for your information and reference.
Midyear Preventive Schedule Changes 2021
The preventive schedule is updated twice a year for updated federal mandates: once in January and once in July. The following changes were made effective on July 1, 2021:
- Screening Sexually Transmitted Infections (STIs): The United States Preventive Services Task Force (USPSTF) recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. This is a reaffirmation of the previous recommendation and already a preventive benefit.
- Screening Illicit Drug Use In Adults: The USPSTF recommends screening for illicit drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.
- This may be billed once a year with a routine exam diagnosis code with either the 99408 or 96160 procedure code
- Adult Nutritional Counseling: The USPSTF recommends patients with cardiovascular disease risk be offered/referred to behavioral counseling interventions to promote a healthy diet and physical activity regardless of the member’s Body Mass Index (BMI).
- This includes hypertension, high blood pressure, metabolic syndrome, and hyperlipidemia diagnosis codes I10 R03.0, E88. 81, E78.5, E78.1, E78.2, E78.3, E78.49, E78.6, E78.9 when billed with procedure codes 97802, 97803, 97804, 99401, 99402, 99403, 99404
- Adult Nutritional Counseling BMI Expansion: The current overweight obesity nutritional counseling benefit has been expanded to include Morbid Obesity Body Mass Index (BMI) codes:
- Morbid Obesity BMI Diagnosis Codes E66.01, E66.09. E66.1, E66.2, E66.8, Z68.42, Z68.43, Z68.44, Z68.45 with procedure codes 97802, 97803, 97804, 99401, 99402, 99403, 99404
Reimbursement, Claims & Billing
NEW AND UPDATED REIMBURSEMENT POLICIES
Highmark regularly issues new or updated reimbursement policies. Keep an eye on the Provider Resource Center Home Page for eBulletins announcing new policies and the Reimbursement Policy page for policy updates.
To access Highmark reimbursement policy bulletins, select CLAIMS, PAYMENT & REIMBURSEMENT from the Provider Resource Center main menu, and then click on REIMBURSEMENT POLICY.
Watch for Updates to Highmark’s List of Procedures Requiring Authorization
During the year, Highmark adjusts the List of Procedures and Durable Medical Equipment (DME) Requiring Authorization, which includes outpatient procedures, services, DME, and drugs that require authorization for our members.
These changes are announced in the form of Special eBulletins that are posted on Highmark’s Provider Resource Centers (PRC).
To view the List of Procedures/DME Requiring Authorization, click Requiring Authorization in the gray bar near the top of the PRC homepage.
Please note that the Highmark member must be eligible on the date of service and the service must be a covered benefit for Highmark to pay the claim.
You may use NaviNet® or the applicable HIPAA electronic transactions to:
- Check member benefits and eligibility
- Verify if an authorization is needed
- Obtain authorization for services
If you are not signed up for NaviNet or do not have access to the HIPAA electronic transactions, please call Clinical Services to obtain an authorization for services: