A newsletter for Highmark Blue Shield providers in central Pennsylvania, the Lehigh Valley, northeastern Pennsylvania, and southeastern Pennsylvania
Issue 5, May 2024
Effective July 15, 2024, Highmark will make its annual update to our standard professional fee and pricing methodology, which applies to the following Highmark service areas — Delaware, Pennsylvania, and West Virginia — for commercial lines of business.
This change does not affect Highmark’s Medicare, Medicaid, or any value-based fee schedule adjustments. The annual update is part of Highmark’s continued effort to align with industry standard values and remains non-negotiable for contracted providers. To read the Special Bulletin, click here
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Highmark will increase fees for most prosthetics and orthotics procedure codes in Delaware, Pennsylvania, and West Virginia, effective July 1, 2024. This adjustment enables Highmark to maintain a consistent fee schedule in alignment with industry standards.
The following lines of business will be impacted:
To learn more, go here.
The 28th edition of MCG’s Care Guidelines will be available on Aug. 1, 2024.
After that date, you will be able to submit authorization requests using the 28th edition for any new requests. Any authorization requests with a start of care date prior to Aug. 1, 2024, will be reviewed using the 27th edition.
Please continue to use the Predictal Auth Automation Hub application in Availity® to submit authorization requests with clinical information included.
Medical Policy (MP) S-249 Amniotic Membrane and Amniotic Fluid Typing was recently published with a line of experimental and investigational procedure codes omitted. This error has been corrected and the policy was updated on May 17, 2024.
To view MP S-249 policy, go to the Provider Resource Center. On the top task bar, click the drop-down arrow for MEDICAL POLICY SEARCH, select MEDICAL POLICIES, and then type “S-249” into the search bar.
The Centers for Medicare and Medicaid Services (CMS) is requiring that insurers, including Highmark, collect additional documentation from facilities for Quality Improvement Organization (QIO) program audits, effective January 1, 2024.
For these audits, facilities will now be required to submit the following documents:
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Professional providers who use Availity® for claim submission now have access to the Quick Claims functionality for Highmark members. Quick Claims allows providers to create templates that pre-populate certain fields when submitting a CMS-1500 claim. This will save time for providers who routinely submit claims for the same patient or same service each week or each month. To learn more, go here.
To assist providers with claims submission for highly complex medical conditions, Highmark has created the Inpatient Facility Diagnosis Guidelines page on the Provider Resource Center (PRC) via Payer Spaces in Availity®.
Providers will find detailed information, including diagnostic thresholds and accurate coding guidance, on a variety of conditions, including Acute Respiratory Failure, Malnutrition, and Sepsis and Septic Shock. To view the Special Bulletin, click here.
