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MARCH 2018
HIGHMARK BLUE SHIELD OFFICE MANUAL TABLE OF CONTENTS
How to Use This Manual Disclaimer Introduction
CHAPTER 1 PROVIDER SERVICES AND INFORMATION SOURCES Unit 1:
Quick Reference Directory Unit 2: Highmarks Informational
Resources
CHAPTER 2 PROVIDER PARTICIPATION AND RESPONSIBILITIES Unit 1:
How to Participate in Highmarks Networks Unit 2: Network
Credentialing Procedures Unit 3: Network Requirements and
Procedures Unit 4: PCP Policies and Procedures for All Products
Updated! Unit 5: Specialist Basics Updated! Unit 6: Behavioral
Health Providers Updated! Unit 7: Ancillary Providers Unit 8: Ohio
Healthcare Simplification Act
CHAPTER 3 PRODUCTS, MEMBERS, AND PAYMENT Unit 1: Product
Information Unit 2: Highmark Member Information Unit 3: Payment
Methodology Unit 4: Pharmacy and Formulary Unit 5: The BlueCard
Program Unit 6: Medicare Advantage Products and Procedures Unit 7:
Telemedicine Services Updated!
CHAPTER 4
HEALTH CARE MANAGEMENT Unit 1: Care Management and Case
Management Unit 2: Introduction to Authorizations Unit 3:
Requesting an Authorization Unit 4: Denials, Grievances, and
Appeals Unit 5: Highmark Quality Program
CHAPTER 5 CLAIMS SUBMISSION Unit 1: Benefits of Electronic
Communication Unit 2: Claims Submission and Billing Information
Updated! Unit 3: 1500 Health Insurance Claim Form Submission
CHAPTER 6 POLICIES AND PROCEDURES Unit 1: Other Party Liability
Unit 3: Payment Review Unit 4: Outpatient Radiology and Other
Diagnostic Services
APPENDIX Highmark Inc. Third Party Code of Business Conduct
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HOW TO USE THIS MANUAL
The Highmark Blue Shield Office Manual (HBSOM) is designed to be
your primary reference guide to doing business with Highmark. It
contains information specific to procedures required of Highmark
network participating providers and is intended as a companion to
other Highmark provider publications.
The HBSOM is binding upon providers and may be supplemented or
superseded, in whole or in part, by other Highmark guidance and/or
requirements furnished or otherwise made available to
providers.
TIPS FOR USING THIS MANUAL
Most recent updates are in Blue Italics: The most recent changes
are presented in blue italic text to denote areas of revision or
addition. The revision dates in the upper right corner of each page
indicate the date those blue revisions were made to the unit.
Resource for all Highmark service areas: Because the manual
applies to all service areas in Pennsylvania, Delaware, and West
Virginia, only the Highmark Blue Shield brand will be referenced.
The icon for the What Is My Service Area? map can be found
throughout the manual to help you determine the service area for
your location.
Information specific to a service area: For information that
does not apply to all service areas, either separate links will be
provided or the information will be designated for a specific area
by the use of an icon indicating the specific state or states to
which the information applies. A key to the state icons appears on
the first page of each unit.
Organized by Chapters/Units: To make it easier to find answers,
the manual is organized by chapters/units and a detailed list of
topics is provided on the first page of each unit.
Tip Sheets: The links for tip sheets are incorporated throughout
the manual. By clicking the links or Tip Sheet icons embedded in
applicable sections, you can access printable desk references on
various topics. All tip sheets are available in one location
through the Tip Sheet Index link at the bottom of the HBSOM home
page.
Office Manual Archive: The archive contains the most recently
retired units of the Highmark Blue Shield Office Manual. Earlier
versions of units are available upon request; requests can be
directed to the HBSOM Editor.
Cant find the topic you are looking for in the Table of Contents
on the home page? Click on Click Here to View/Print Entire Manual
and enter your key word in the search box.
Intended to be an online resource: Keeping the HBSOM electronic
allows us to provide you with the most up-to-date information. All
revisions to this manual are controlled electronically. Paper
copies and screen prints are considered uncontrolled and may not be
the most recent revision.
e-Subscribe By selecting e-Subscribe on the Provider Resource
Center, you may sign up for email notifications of updates made to
the Office Manual. Just complete the requested information,
checking the Professional Provider box in Step 4, and then click on
the Subscribe button.
This manual is the result of provider feedback. If you would
like to comment on or make suggestions for additional improvements
to the Highmark Blue Shield Office Manual, please email your
comments to [email protected]. Please include your name and
telephone number for the HBSOM Editor to contact you if
necessary.
https://www.highmark.com/health/pdfs/hbsom-map.pdfmailto:[email protected]://www.highmark.com/health/pdfs/hbsom-entiremanual.pdfmailto:[email protected]
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FEBRUARY 2016
HIGHMARK BLUE SHIELD OFFICE MANUAL | DISCLAIMER
DISCLAIMER
Disclaimer All revisions to this manual are controlled
electronically. All paper copies and screen prints are considered
uncontrolled and should not be relied upon for any purpose. The
Highmark Blue Shield Office Manual (HBSOM) is the property of
Highmark Inc. The information, content, and design/organization of
the Highmark Blue Shield Office Manual are maintained by Highmark.
Links to external websites referenced in the manual are for the
convenience of the user. Such links do not constitute an official
endorsement or approval by Highmark or subsidiaries. Some
information in the Highmark Blue Shield Office Manual is subject to
change without prior notice. Such changes may be published in
provider newsletters or sent in special mailings. The Highmark Blue
Shield Office Manual is binding upon providers and may be
supplemented or superseded, in whole or in part, by other Highmark
guidance and/or requirements furnished or otherwise made available
to providers, provided supplements do not conflict with the
applicable federal and state laws and regulations. Highmark
complies with all state and federal laws related to Medicare and
our Medicare Advantage products. In cases where Highmark policy,
Highmark Medical Policy, and/or the Highmark Blue Shield Office
Manual conflict with Centers for Medicare & Medicaid Services
(CMS) laws, regulations, or directives, the CMS laws, regulations,
and/or directives shall apply.
20072017 Highmark Inc. All rights reserved.
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HIGHMARK BLUE SHIELD OFFICE MANUAL | INTRODUCTION 1 | P a g
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HIGHMARK BLUE SHIELD OFFICE MANUAL A PROCEDURAL GUIDE FOR
PROVIDERS
Purpose The Highmark Blue Shield Office Manual contains an
integrated set of procedures and policies that apply to Highmark
network participating professional provider offices within
Pennsylvania, Delaware, West Virginia, and contiguous counties in
their bordering states.
The manual is designed to give you access to information such as
claims filing, researching patient benefits, and joining one of
Highmark's networks. It also includes important information on how
to communicate with Highmark through automated and electronic
systems which is the most efficient and convenient method for you
and your office staff.
The Highmark Brand
Because this manual combines information for all service areas
in Pennsylvania, Delaware, and West Virginia, you will only see a
reference to the Highmark Blue Shield brand.
Where business applies to a particular service area only, it
will be noted as such (see key below), or the information will be
broken out into a separate link. If you are uncertain of your
service area, please click the What Is My Service Area? icon, which
is located throughout the manual.
Legal Information
Legal information can be viewed by clicking the link below:
Highmark Blue Shield Office Manual Legal Information
2007 2017 Highmark Inc. All rights reserved.
What Is My Service Area?
https://www.highmark.com/health/pdfs/hbsom-legal-info.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf
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INTRODUCTION
A GUIDE TO HIGHMARK
IN THIS UNIT
TOPIC SEE PAGE Providing Access, Information, and Direction 3
About Highmark Inc. 6 Highmark Partners with Health Care
Professionals 8 Prioritizing Electronic Claims Submission 11
Highmark Inc. Board of Directors 12 The Board of Directors of
Highmark Delaware 13 The Board of Directors of Highmark West
Virginia 14
What Is My Service Area?
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PROVIDING ACCESS, INFORMATION, AND DIRECTION
Overview and manual history
This manual is designed to be your primary reference guide to
Highmark. The Highmark Blue Shield Office Manual (HBSOM) gives you
access to the information you need to do such things as file
claims, research patient benefits, and join one of our networks. It
also lists additional informational resources should your questions
require a more in-depth explanation. The HBSOM is intended to be a
companion to other Highmark provider publications. The HBSOM
contains information specific to procedures required of providers
participating in Highmarks professional provider networks in
Pennsylvania, Delaware, and West Virginia. The manual combines
information for these service areas to give practitioners a
comprehensive understanding of Highmarks health insurance programs.
The HBSOM was originally published in 2007 as the result of the
consolidation and renovation of the manuals previously available in
Pennsylvania: the Highmark Blue Shield Reference Guide and the
Highmark Blue Shield Reference Guide Western Version. In 2013,
information was incorporated for professional providers
participating in Highmarks Delaware provider network; and in 2016,
the manual consolidation for all service areas became complete with
the inclusion of Highmark West Virginia. This online manual
replaces any older versions of the HBSOM and/or Highmark Blue
Shield Reference Guide and/or Highmark Blue Shield Reference Guide
Western Version, the BlueCross BlueShield of Delaware Provider
Manual, the Highmark West Virginia Provider Manual, and any
predecessor provider manuals used in any of Highmarks service
areas.
Who should use this manual?
The Highmark Blue Shield Office Manual is binding upon providers
and may be supplemented or superseded, in whole or in part, by
other Highmark guidance and/or requirements furnished or otherwise
made available to providers. The policies and procedures outlined
in this manual primarily focus on medical services provided in a
medical office or non-facility setting. Ancillary providers are
encouraged to visit Chapter 2, Unit 7 of the HBSOM and other
ancillary-specific material throughout the manual as primary
reference points for ancillary reference materials. Behavioral
health providers are encouraged to visit Chapter 2, Unit 6 of the
HBSOM and where applicable throughout the manual as primary
reference points for behavioral health materials.
Continued on next page
What Is My Service Area?
https://www.highmark.com/health/pdfs/hbsom-chapter2-unit7.pdfhttps://www.highmark.com/health/pdfs/hbsom-chapter2-unit6.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf
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PROVIDING ACCESS, INFORMATION, AND DIRECTION, Continued
Regulatory compliance and review
Information in the HBSOM is subject to regulatory review and may
be changed at any time in accordance with regulatory requirements.
Such changes may also be published in provider newsletters and/or
special mailings. Individual situations are governed by the terms
of the specific applicable contracts and/or Medical Policy.
Highmark complies with all state and federal laws related to
Medicare and our Medicare Advantage products. In cases where
Highmark policy, Highmark Medical Policy, and/or the HBSOM conflict
with Centers for Medicare & Medicaid Services (CMS) laws,
regulations, or directives, the CMS laws, regulations, and/or
directives shall apply. In addition to the HBSOM, please check the
Provider Resource Centers Publication and Mailings section often
for policy and procedure updates.
How to use this manual
The HBSOM is specifically dedicated to professional providers
and contains helpful information and resources to help in your
daily interactions with Highmark members and with Highmark.
Highmark encourages you to bookmark the Office Manual site to take
full advantage of this convenient reference tool. The HBSOM is
organized by topic to make it easier for you to find answers. The
first page of each unit provides a detailed list of the topics
covered in that unit. The HBSOM is intended to be an online
resource. Keeping the HBSOM electronic allows us to keep our
promise to provide you with the most up-to-date information. All
revisions to this manual are controlled electronically. Paper
copies and screen prints are considered uncontrolled and may not be
the most recent revision. The most recent changes in the manual are
presented in blue italic print to denote areas of revision or
addition. This visually attractive format works in conjunction with
revision dates in the upper right corner of each page. This style
is designed to help you find updated information more quickly.
You can click on the link located throughout the manual for an
explanation of the blue italics as well as additional helpful tips
for getting the most from the Highmark Blue Shield Office Manual.
This document is also accessed from the How to Use This Manual link
at the top of the HBSOM home page.
Continued on next page
Why blue italics?
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PROVIDING ACCESS, INFORMATION, AND DIRECTION, Continued
Tip sheets Highmark has incorporated a printable tip sheet
feature into the HBSOM. The
link for tip sheets will be incorporated throughout the manual
where available. All tip sheets available within the manual are
also accessible from the Tip Sheet Index. The index link is located
at the bottom of the HBSOM home page. Please click the link
embedded in applicable sections for a quick, printable desk
reference.
How to provide feedback
This manual is the result of feedback from our providers. To
ensure this manual continues to fulfill its objective, Highmark is
interested in comments from readers. If you would like to recommend
improvements to the Highmark Blue Shield Office Manual, please
contact us. Email your comments to:
[email protected] Please include your name and telephone
number for the Editor to contact you, if necessary, to clarify your
recommendations.
Tip Sheet
mailto:[email protected]
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ABOUT HIGHMARK INC.
A brief history of Highmark Inc.
In the 1930s, Highmark Inc.'s predecessor companies were
established to help individuals in the communities they served to
pay for hospital and medical services. Today, that remains our
mission to deliver high quality, accessible, understandable, and
affordable experiences, outcomes, and solutions for our customers.
It guides our actions throughout Highmark's businesses.
Highmark Inc. (Highmark) was created in 1996 by the
consolidation of two Pennsylvania licensees of the Blue Cross and
Blue Shield Association Pennsylvania Blue Shield and Blue Cross of
Western Pennsylvania. Highmark now operates health insurance plans
in Pennsylvania, Delaware, and West Virginia that serve 5.2 million
members:
Highmark Blue Shield serves the 21 counties of central
Pennsylvania and the Lehigh Valley as a full-service health
plan.
Highmark Blue Cross Blue Shield provides integrated Blue Cross
and Blue Shield coverage throughout the 29 counties of western
Pennsylvania and, beginning in 2015, the13 counties in northeastern
Pennsylvania previously known as Blue Cross of Northeastern
Pennsylvania.
Highmark Blue Cross Blue Shield Delaware, previously known as
BlueCross BlueShield of Delaware, joined the Highmark family as an
affiliate at year-end 2011. The affiliation agreement enabled
Highmark Delaware to maintain its strong presence throughout the
state as a local, not-for-profit company.
Highmark Blue Cross Blue Shield West Virginia is the states
largest health insurance carrier and serves all of West Virginias
55 counties plus Washington County in the state of Ohio. In 2011,
the former Mountain State Blue Cross Blue Shield changed its name
to reflect the 12-year affiliation it had with Pennsylvania-based
Highmark.
We also cooperatively market health insurance products in
southeastern Pennsylvania through a joint operating agreement with
Independence Blue Cross.
Our national health business includes administration of
self-funded groups, third-party administration, network access
arrangements, claims processing, and other services on behalf of
Blue Cross and Blue Shield plans throughout the country. Our
participation in the BlueCard Program offers members benefits
through provider networks of other Blue Cross and Blue Shield plans
nationally and worldwide.
Continued on next page
What Is My Service Area?
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ABOUT HIGHMARK INC., Continued
Highmark Health
Highmark Health is a diversified health and wellness enterprise
based in Pittsburgh. Highmark Health employs 38,000 people and
serves 35 million individuals, making it the third largest
integrated health care delivery and financing network in the
nation. In 2011, Highmark Health became one of the first in the
nation to take steps to evolve from a traditional health insurance
company to an integrated health and wellness company with a
patient-centered care delivery system. Highmark Health is the
parent company of Highmark Inc. and also the parent company for
Allegheny Health Network, an integrated health care delivery
network that currently includes eight hospitals, physician
organizations, a group purchasing organization, and ambulatory
surgery centers.
Highmark also offers health and wellness products to clients
with employees throughout the United States. The companys
diversified businesses provide a spectrum of specialty products
such as dental insurance, vision care, and supplemental health
programs across the country. In addition, Highmark operates more
than 600 optical retail stores (Visionworks) and five U.S.-based
eyewear manufacturing facilities.
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HIGHMARK PARTNERS WITH HEALTH CARE PROFESSIONALS
An ongoing commitment to health care professionals
Highmark has been a partner with the medical community since the
1930s and understands the tremendous value that physicians and
other health care professionals bring to its organization and to
its members. That is why Highmark is constantly striving to make
its relationships stronger and better through:
Enhancing electronic communications and the exchange of data
electronically through websites like NaviNet.
Providing a number of different ways for health care
professionals to obtain information -- from websites to toll-free
telephone numbers, fax-back services, and Provider Services
representatives.
Partnering with providers to implement programs that lead to
better medical outcomes for our members.
Restructuring our credentialing process to make it easier and
more efficient.
Physicians heavily involved in governance and policy
decisions
At Highmark, physicians and other health care professionals play
an important role in the companys governance and policy-making.
They have more representation on Highmarks governing bodies than
many other insurance companies. Over 500 independent health care
professionals are active in a variety of positions that influence
the core of Highmarks operations they make up the majority of
committees that help define Medical Policy, resolve claims
disputes, and promote the delivery of quality medical care to
Highmark members. Health care professionals are also involved at
various key junctures during the development of Highmarks Medical
Policy the guidelines used in our coverage and reimbursement
determinations.
Highmark Inc. Board of Directors
The Board of Directors of Highmark Inc. includes health care
professionals (referred to as Professional Directors) and
representatives from customers, hospitals, and the community
(referred to as Lay Directors). The bylaws of the Corporation
require that twenty-five (25) percent of the Board of Directors (or
as close as practicable) be Professional Directors. The business
and affairs of the Corporation are managed under the direction of
the Board of Directors.
Professional Consultant Network
This approximately 250-member group is comprised of health care
professionals in active practice. Highmark relies on their expert
counsel to ensure the accurate and fair disposition of medical
reviews and to provide guidance when developing medical policy.
Continued on next page
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HIGHMARK PARTNERS WITH HEALTH CARE PROFESSIONALS, Continued
Highmarks Quality Program Committees
Highmarks Quality Program Committees are made up predominantly
of health care professionals.
Clinical Policy Management Committee (CPMC) The CPMC is
responsible for evaluating medical and surgical procedures and
techniques, determining the medical policy coverage positions, and
recommending medical necessity guidelines for covered
procedures.
Specialty Subcommittees Specialty subcommittees -- made up of
actively practicing physicians in the areas of Cardiology,
Hematology/Oncology, Musculoskeletal, and Neurosciences -- evaluate
existing medical policy coverage guidelines as well as new
technology. The subcommittees meet quarterly and make
recommendations to the CPMC regarding medical policy coverage
positions.
Highmark Quality, Safety, and Value Committee (HQSVC) The HQSVC
is a physician-based committee that provides clinical oversight of
quality program activities on behalf of the Highmark Board of
Directors. The committee reviews quality assurance and improvement
activities related to the health benefits administered by Highmark
and its wholly-owned, wholly-controlled, and/or partially-owned
subsidiaries, and provides input and recommendations on such
activities. The HQSVC reviews and approves the quality program
description, action plan, and evaluation on an annual basis. The
HQSVC also receives quality program reports and updates, as
appropriate.
Quality Management Council (QMC) The QMC meets quarterly and is
responsible for review and approval of the following information:
quality program description, action plan, and evaluation on an
annual basis; credentialing policies and desktop procedures; URAC
quality improvement project selection; and quality committee
reports. The QMC is also responsible for recommending policy
decisions, analyzing and evaluating the results of quality
activities, ensuring practitioner participation in the quality
program, instituting needed actions, and ensuring follow-up, as
appropriate. This includes, but is not limited to, the results of
quality monitoring activities completed specific to member
satisfaction, health care equity, accessibility of services,
practitioner and provider availability, continuity of care,
credentialing and recredentialing, delegation and business
arrangement oversight, and ongoing regulatory and accrediting body
compliance.
Continued on next page
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HIGHMARK PARTNERS WITH HEALTH CARE PROFESSIONALS, Continued
Highmarks Quality Program Committees (continued)
Clinical Advisory Committee (CAC) The physician-based CAC serves
to provide input and direction into the clinical quality activities
and initiatives of the plan. The CAC reports to the QMC and was
given authority to oversee the clinical activities of the Internal
Clinical Work Group. The CAC is comprised of practicing Highmark
network physicians and other clinical representatives from primary
care and appropriate specialties. The committee is chaired by the
Medical Director, Clinical Services and is responsible for
providing input and direction to the Internal Clinical Work Group
for the selection and adoption of preventive/chronic care
initiatives; identifying outcome measures; quantitative and
qualitative data analyses, implementation of intervention
strategies, and re-evaluation; and reviewing and approving clinical
practice and preventive health guidelines. The CAC meets two times
a year.
Health Equity Professional Advisory Committee (HEPAC) HEPAC
serves as a professional clinical advisory committee charged with
the selection, planning/design, prioritization, and monitoring of
the enterprise-wide efforts dedicated to reducing health care
disparities, enhancing health literacy, and providing culturally
and linguistically appropriate services (CLAS). The HEPAC
membership is comprised of practicing Highmark network physicians
and other health care professionals with expertise in community
health and/or practice with minority or disparate populations. The
HEPAC meets at least annually and is chaired by the Senior Medical
Director of Highmarks Health Equity and Quality Services (HEQS)
area.
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PRIORITIZING ELECTRONIC CLAIMS SUBMISSION
Overview Highmark has placed a high priority on electronic
claims filing and the electronic
exchange of information. This process is more efficient and
cost-effective than conventional means benefiting health care
professionals, members, and insurers.
EDI Services and NaviNet
The companys electronic commerce division, Highmark Electronic
Data Interchange (EDI) Services, provides a host of services that
make filing claims and accessing information faster and easier.
These include:
A claims clearinghouse where you can electronically submit
claims and inquiries for Highmark.
Convenient technical support through a toll-free hotline.
Information on getting started in electronic claims filingincluding
a list
of vendors who can help you with the appropriate computer
equipment and software. These vendors can also help you use your PC
to automate other office processes.
In addition, NaviNet is made available at no cost to Highmark
network participating providers. NaviNet is an Internet-based
application for providers to streamline data exchanges between
their offices and Highmark. Providers are able to submit claims
through the HIPAA-compliant claim submission function on NaviNet.
This provider portal also allows providers to verify enrollment,
eligibility, claims status, and much more.
FOR MORE INFORMATION
Please see Chapter 5, Unit 1, Benefits of Electronic
Communication, in the Highmark Blue Shield Office Manual for a
complete overview of Highmarks electronic capabilities and
offerings. For more information on NaviNet, please see Chapter 1,
Unit 2.
What Is My Service Area?
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HIGHMARK INC. BOARD OF DIRECTORS
Board of Directors of Highmark Inc.
The top level of governance of Highmark Inc. is its Board of
Directors. Working hand-in-hand with the Officers of the
Corporation, the board determines the company's strategic direction
and high-level corporate policies.
David L. Holmberg, Chairman of the Board of Directors of
Highmark Inc. President and CEO, Highmark Health
Pittsburgh, PA
Joseph C. Guyaux (Lead Director) Retired Executive, PNC Bank
Pittsburgh, PA Chairman of the Board of Directors for
Highmark Health
Glen T. Meakem President & CEO, FOREVER
Pittsburgh, PA
David A. Blandino, MD Family Physician
Clinical Associate Professor of Family Medicine at University of
Pittsburgh
School of Medicine Pittsburgh, PA
Steven M. Hoffman, CPA Retired, Mid-Atlantic Area Tax Risk
Management Partner, KPMG Harrisburg, PA
John J. Menapace Retired, Vice President and Chief
Administrative Officer C-Tec Corp.
Clarks Summit, PA
Richard W. Bloomingdale President, PA AFL-CIO
Harrisburg, PA
Calvin B. Johnson, MD, MPH Principal
Altre Strategic Solutions Group, LLC Penn Valley, PA
John P. Moses, ESQ Cozen OConnor LLP
Wilkes-Barre, PA
R. Yvonne Campos President, Net Act Fund
Pittsburgh, PA
Gregory B. Jordan, ESQ Executive Vice President, General
Counsel & Chief Administrative Officer PNC Financial
Services Group, Inc.
Pittsburgh, PA
Victor A. Roque, ESQ Retired, President
Duquesne Light Company Allison Park, PA
Thomas J. Castellano, MD Digestive Care Associates
Edwardsville, PA
Mark S. Kamlet, PhD University Professor of Economics and
Public Policy and Provost Emeritus Carnegie Mellon
University
Pittsburgh, PA
Susan W. Shoval President
Shoval Enterprises Kingston, PA
Louis A. Civitarese, DO, MMI Preferred Primary Care
Physicians
Carnegie, PA
Gary F. Lamont Principal, Conyngham Pass Company
Sugarloaf, PA
Rhea P. Simms CEO, Lewith & Freeman Real Estate, Inc.
Shavertown, PA
Thomas R. Donahue CFO and Treasurer, Federated
Investors, Inc., and CEO, Federated Investors Management
Company
Pittsburgh, PA
David J. Malone President and CEO Gateway Financial
Gibsonia, PA
Doris Carson Williams President and Chief Executive Officer
African American Chamber of Commerce of Western Pennsylvania
Pittsburgh, PA
Don P. Foster, ESQ Principal
Offit Kurman Philadelphia, PA
David M. Matter Chief Executive Officer, Retired and
Chairman of the Executive Committee Oxford Development
Company
Pittsburgh, PA
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THE BOARD OF DIRECTORS OF HIGHMARK DELAWARE
Board of Directors of Highmark BCBSD Inc.
The Board of Directors of Highmark Blue Cross Blue Shield
Delaware Inc. are as follows:
William H. Willis, Jr. Chairperson of Board
President, Willis Chevrolet, Inc. Smyrna, DE
President, Willis Ford, Inc. Smyrna, DE
Timothy J. Constantine Director
EVP, Commercial Markets Highmark Inc. Pittsburgh, PA
President Highmark BCBSD Inc.
Wilmington, DE
W. Dennis Cronin Director
SVP, Assistant Treasurer & Risk Officer Highmark Health
Pittsburgh, PA
Randeep S. Kahlon, M.D. Director
Orthopaedic Surgeon & Physician Leader
Delaware Hand to Shoulder Center at First State Orthopaedics
Wilmington, DE
David P. Roselle, PhD Director
Executive Director Winterthur Museum & Country Estate
Wilmington, DE Past President
University of Delaware Newark, DE
Jean Rush Director
EVP, Government Markets Highmark Inc.
Michael G. Warfel Director
VP Government Affairs Highmark Inc. Camp Hill, PA
Frances M. West, Esquire Director
Retired, State of Delaware Governor-appointed positions
held:
Highway Commissioner, Director of Consumer Affairs, and
Secretary of Community Affairs Past President
Better Business Bureau of Delaware New Castle, DE
Gregory B. Williams, Esquire Director
Equity Partner Fox Rothschild LLP
Wilmington, DE
What Is My Service Area?
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THE BOARD OF DIRECTORS OF HIGHMARK WEST VIRGINIA
Board of Directors of HMKWV and HSSC
The Board of Directors of Highmark West Virginia Inc. d/b/a
Highmark Blue Cross Blue Shield West Virginia (HMKWV) and also
Highmark Senior Solutions Company (HSSC) are as follows:
Lawrence Brent Boggs West Virginia House of Delegates
Chair, Committee on Finance Charleston, WV
James Bernard Hayhurst, Jr. Retired, EVP, United Bank, Inc.
Parkersburg, WV
David Lee Campbell Acting CEO, West Virginia Health
Improvement
Institute, Inc. Barboursville, WV
CEO, Community Health Network of WV Barboursville, WV
Robert Michael Robinson President, Robinson Automotive Group
Wheeling, WV
Timothy John Constantine EVP, Commercial Markets
Highmark Inc. Pittsburgh, PA
Brian David Setzer SVP, CFO, Highmark Health Plans
Highmark Inc. Pittsburgh, PA
John Frederick Earley, II Retired, Market President
Highmark West Virginia Inc. Parkersburg, WV
Judith Wilena Sjostedt Executive Director, PACF and Regional
Affiliates
Parkersburg, WV
James L. Fawcett Market President
Highmark West Virginia Inc. Parkersburg, WV
Michael G. Warfel VP, Government Affairs
Highmark Inc. Camp Hill, PA
What Is My Service Area?
Why blue italics?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 1 | P a g e
CHAPTER 1: PROVIDER SERVICES AND INFORMATION SOURCES
UNIT 1: QUICK REFERENCE DIRECTORY
IN THIS UNIT
TOPIC SEE PAGE Overview 2 Mailing Addresses 3 Telephone and Fax
Numbers 7
What Is My Service Area?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 2 | P a g e
1.1 OVERVIEW
Introduction
This unit includes information on claims mailing addresses,
inquiry mailing addresses, and telephone and fax numbers for all of
Highmarks service areas:
Pennsylvania Western Region including 29 counties in western
Pennsylvania Central Region includes 21 counties in central
Pennsylvania Eastern Region includes 5 counties in eastern
Pennsylvania Northeastern Region -- includes 13 counties in
northeastern
Pennsylvania
Delaware -- including all three counties in Delaware
West Virginia -- including all 55 counties of West Virginia and
Washington County, Ohio
Contact information tip sheets
Please click on the applicable link below for a printable desk
reference with complete Highmark contact information for providers
for your service area.
Highmark Contact Information for Pennsylvania Providers
Highmark Delaware Contact Information for Providers
Highmark West Virginia Contact Information for Providers
What Is My Service Area?
https://www.highmark.com/health/pdfs/contact-info-pa.pdfhttps://www.highmark.com/health/pdfs/contact-info-pa.pdfhttps://www.highmark.com/health/pdfs/contact-info-de.pdfhttps://www.highmark.com/health/pdfs/contact-info-wv.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 3 | P a g e
1.1 MAILING ADDRESSES
Claims filing addresses
If you still submit claims to Highmark on paper, please click
the appropriate link below for a list of Claim Filing Addresses in
your service area.
PA Western Region Claims Filing Addresses
PA Central, Eastern, and Northeastern Claims Filing
Addresses
Delaware Claims Filing Addresses
West Virginia Claims Filing Addresses For questions about
submitting claims electronically, providers from all Highmark
service areas can call the Highmark EDI Operations support line at
1-800-992-0246 to speak with a representative.
IMPORTANT! Only original paper claim forms accepted
Highmark will accept and process only original red 1500 Health
Insurance Claim Forms, Version 02/12. Photocopies or outdated
versions of the form will be returned to the provider. The provider
will need to resubmit the returned claims on the appropriate form.
Highmark utilizes the Optical Character Recognition (OCR) scanning
system to assure accurate and efficient processing of paper claims.
The OCR Scanner is programmed to read only the original red 02/12
version of the 1500 form.
How to obtain 1500 claim forms
To obtain a supply of 02/12 1500 forms, please contact your
forms distributor. If your forms distributor needs a negative or
PDF of the claim form, they should contact:
TFP Data Systems: Send email to [email protected] ,or call
1-800-482-9367, Ext. 1770
Government Printing Office: Call 1-202-512-1800
Continued on next page
What Is My Service Area?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 4 | P a g e
1.1 MAILING ADDRESSES, Continued
Highmark forms
Highmark provides recommended forms that providers may use when
communicating with Highmark, Highmark members, or other providers
in the network. The forms are readily available online on the
Provider Resource Center; select FORMS from the main menu. If you
require forms that are not available on the Provider Resource
Center, forms may be ordered by writing to: Highmark Shipping
Control P.O. Box 890089 Camp Hill, PA 17089-0089 Please include the
form number and title, quantity, and shipping address.
Premier Blue Shield allowances and UCR profile
To obtain a copy of Premier Blue Shield allowances for the most
frequently reported codes for your specialty or a copy of your
Highmark Blue Shield UCR profile, send a letter of request to: Fee
Based Pricing and Analysis Highmark Blue Shield P.O. Box 890089
Camp Hill, PA 17089-0089 Include your Highmark provider ID number,
full name, address, and indicate whether you are requesting your
UCR profile, Premier Blue Shield allowances, or both. This
information is also available via NaviNet for those NaviNet-enabled
offices.
Refund checks for HSA, HRA, and FSA overpayments only
These postal addresses are to be used solely for overpayments
from: Health Savings Accounts (HSAs) Health Reimbursement Accounts
(HRAs) Flexible Spending Accounts (FSAs)
PENNSYLVANIA DELAWARE WEST VIRGINIA
Highmark Attn: Cashier P.O. Box 890150 Camp Hill, PA
17001-9774
Highmark Blue Cross Blue Shield Delaware Attention: Treasury
P.O. Box 1991 Wilmington, DE 19899-1991
Highmark Attn: Cashier P.O. Box 890150 Camp Hill, PA
17001-9774
Continued on next page
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 5 | P a g e
1.1 MAILING ADDRESSES, Continued
Refund checks for all other payments
PENNSYLVANIA DELAWARE WEST VIRGNIA Highmark Attn: Cashier P.O.
Box 898820 Camp Hill, PA 17089-0150
Highmark Blue Cross Blue Shield Delaware Attention: Treasury
P.O. Box 1991 Wilmington, DE 19899-1991
Highmark Attn: Cashier P.O. Box 898820 Camp Hill, PA
17089-0150
Practice information updates
NaviNet-enabled practitioners should make their practice
information changes via Provider File Management in NaviNet,
Highmarks preferred method for updating your practice information.
If you are not NaviNet-enabled, complete the Request for
Addition/Deletion to an Existing Assignment Account form for
practitioner changes. To add a new location, change an address, or
update office hours, complete the Provider File Maintenance Request
form. These forms are also available on the Provider Resource
Center --select FORMS, and then click on Provider Information
Management Forms. Written update requests can be faxed or mailed as
follows:
Fax to : 1-800-236-8641 Mail to: Highmark Blue Shield
Provider Information Management P.O. Box 898842 Camp Hill, PA
17089-8842
Pre-service reviews
PENNSYLVANIA DELAWARE WEST VIRGINIA
Highmark 120 Fifth Avenue Place Suite P4301 Pittsburgh, PA
15222-3099
Highmark BCBSDE, Inc. Medical Management Pre-Service Reviews
P.O. Box 1991 Del Code 1-8-40 Wilmington, DE 19899-1991
Highmark Blue Cross Blue Shield West Virginia 200 Tracy Way
Charleston, WV 25311
Continued on next page
What Is My Service Area?
What Is My Service Area?
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1.1 MAILING ADDRESSES, Continued
Retrospective reviews
PENNSYLVANIA DELAWARE WEST VIRGINIA
Highmark Medical Review P.O. Box 890392 Camp Hill, PA
17089-0392
Highmark BCBSDE, Inc. Medical Management Retrospective Reviews
P.O. Box 1991 Del Code 1-8-40 Wilmington, DE 19899-1991
Highmark Blue Cross Blue Shield West Virginia P.O. Box 1948
Parkersburg, WV 26102
What Is My Service Area?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.1 7 | P a g e
1.1 TELEPHONE AND FAX NUMBERS
Provider Service Center
Please use NaviNet for all of your routine eligibility, benefit,
and claim inquiries. NaviNet is also the preferred method for
authorization requests. For non-routine inquiries that require
analysis and/or research, contact Highmarks Provider Services for
your service area as indicated below.
PA Western Region: 1-800-547-3627 PA Central, Eastern, and
Northeastern Regions: 1-866-731-8080 Delaware: 1-800-346-6262 West
Virginia: 1-800-543-7822
Please listen carefully to the available options to reach the
appropriate area for your inquiry. Hours: 8 a.m. to 5 p.m. Monday
through Friday.
Medicare Advantage Provider Service
Pennsylvania: Freedom Blue PPO: 1-866-588-6967 Community Blue
Medicare HMO: 1-888-234-5374 Security Blue HMO (Western Region
only): 1-866-517-8585
West Virginia: Freedom Blue PPO: 1-888-459-4020
Authorizations and pre-certification inquiries
Medical Management & Policy (MM&P):
PA Western Region: 1-800-547-3627 PA Central and Eastern
Regions: 1-866-731-8080 PA Northeastern Region (for members
transitioned to Highmark health
plans): 1-800-452-8507 Delaware: 1-800-572-2872 West Virginia:
1-800-344-5245
Behavioral Health:
PA Western and Northeastern Regions: 1-800-258-9808 Pa Central
and Eastern Regions: 1-800-628-0816 Delaware: 1-800-421-4577 West
Virginia: 1-800-344-5245
In Pennsylvanias Northeastern Region, please call Blue Cross of
Northeastern Pennsylvania at 1-800-638-0505 for BCNEPA members not
yet transitioned to Highmark health plans. In Pennsylvanias Eastern
Region, please call Independence Blue Cross at 1-800-862-3648.
Continued on next page
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1.1 TELEPHONE AND FAX NUMBERS, Continued
Electronic Data Interchange (EDI)
If you wish to begin to submit claims electronically or need
assistance with electronic claims submission, providers from all
Highmark service areas can call the Highmark EDI Operations support
line at 1-800-992-0246 to speak with a representative.
NaviNet Customer Care
To speak directly to a live NaviNet Customer Care
representative, please call the following number: 1-888-482-8057.
Hours: Monday-Friday 8 a.m. to 11 p.m.; Saturdays 8 a.m. to 3
p.m.
Traditional Medicare
Pennsylvania and Delaware: Novitas Solutions, Inc. (
www.novitas-solutions.com ) Medicare Part A & B Provider
Inquiries: 1-877-235-8073
( TTY: 1-877-235-8051) Hours: Monday-Friday 8:00 a.m.-4:00 p.m.
ET
West Virginia: Palmetto GBA (www.palmettogba.com)
Medicare Part A & B Inquiries: 1-855-696-0705 (TDD: 1-
866-830-3188) Hours: Monday-Friday 8 a.m. 4:30 p.m. ET
What Is My Service Area?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.2 1 | P a g e
CHAPTER 1: PROVIDER SERVICES AND INFORMATION SOURCES
UNIT 2: HIGHMARKS INFORMATIONAL RESOURCES
IN THIS UNIT
TOPIC SEE PAGE A Variety of Information Sources 2 Highmarks
Informational Websites 3 The Provider Resource Center 6 NaviNet
Automated Inquiries and Transactions 8 Provider Publications 11
Special Bulletins and Mailings 13 e-Subscribe 15 Provider Service
Representatives 16
What Is My Service Area?
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.2 2 | P a g e
1.2 A VARIETY OF INFORMATION SOURCES
Overview of information sources for providers
Highmark is committed to providing timely and pertinent
information about our policies and programs to the provider
community. Highmark has a number of easy-to-use electronic sources
of information accessible through your computer as well as
representatives available by telephone. A variety of informational
sources are available for use including:
Highmarks Informational Public Websites:
Highmark.com
PA Central, Eastern, and Northeastern Region
PA Western Region
Delaware
West Virginia
Highmarks Provider Resource Centers for all Service Areas
accessible from Highmark.com, our regional public websites, and
NaviNet:
PA Central, Eastern, and Northeastern Region Provider Resource
Center
PA Western Region Provider Resource Center
Delaware Provider Resource Center
West Virginia Provider Resource Center
Newsletters for Professional and Facility Providers:
Provider News Medical Policy Update
Additional Sources:
NaviNet automated inquiries and transactions Clinical Views
journal for physicians and their clinical staff Special Bulletins
and mailings Electronic subscriptions Provider Service Center
Representatives
What Is My Service Area?
https://www.highmark.com/hmk2/index.shtmlhttps://www.highmarkblueshield.com/chmptl/chm/jsp/Splash.do?site=pbshttps://www.highmarkbcbs.com/chmptl/chm/jsp/Splash.do?site=hbcbshttps://www.highmarkbcbsde.com/chmptl/chm/jsp/Splash.do?site=hbcbsdehttps://www.highmarkbcbswv.com/home/https://prc.highmarkblueshield.com/rscprc/hbs/pubhttps://prc.highmark.com/rscprc/hbcbs/pubhttps://prc.highmark.com/rscprc/hdebcbs/pubhttps://prc.highmark.com/rscprc/hwvbcbs/pubhttps://www.highmark.com/health/pdfs/hbsom-map.pdf
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1.2 HIGHMARKS INFORMATIONAL WEBSITES
Overview Highmarks informational public websites cover all core
business and subsidiary
companies. They provide a broad range of information to
customers, health care professionals, and the public.
Highmark.com To learn about Highmarks history and access
information about Highmark
companies, subsidiaries, and affiliates, visit highmark.com.
This website also provides you with information about Highmarks
community involvement, event sponsorships, and programs. In
addition, you can learn about our Highmark Direct retail stores,
access health and safety tips, and so much more. The public
websites for Highmark plans with service areas in Pennsylvania,
Delaware, and West Virginia can also be accessed from
highmark.com.
Access to the Provider Resource Centers for all service areas is
also available at highmark.com. Click on the CONSUMERS/MEMBERS/
PROVIDERS button.
Continued on next page
What Is My Service Area?
And then select the plan link for your service area.
Click here.
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1.2 HIGHMARKS INFORMATIONAL WEBSITES, Continued
Highmarks public websites
The public websites for Highmark Inc. service areas in
Pennsylvania, Delaware, and West Virginia are as follows:
highmarkbcbs.com--serving the 29 counties of western
Pennsylvania.
highmarkblueshield.com--serving the 21 counties of central
Pennsylvania and the Lehigh Valley and the 14 counties of
northeastern Pennsylvania as well as services offered in
conjunction with Independence Blue Cross in southeastern
Pennsylvania.
highmarkbcbsde.com-- serving the three counties of Delaware.
highmarkbcbswv.com serving the entire state of West Virginia and
Washington County Ohio.
These websites provide information specific to individuals,
members, employers, producers, and providers living in these
locations. You can also access the Provider Resource Center for
your service area from these websites -- just scroll down to the
Helpful Links box, and then click on Provider Resource Center.
Directing our members
When Highmark members have questions related to their coverage,
your office may want to direct them to the appropriate public
website for their service area. On each of these sites, members can
find the following information and more:
Provider, Pharmacy, and Drug Information: By selecting the FIND
DOCTOR OR RX tab, members can access the Highmark Provider
Directory and find information about participating doctors,
hospitals, and other medical providers in their service area. In
addition, this link allows them to search for participating
pharmacies and also access drug formulary information.
Member Login: Members can register on this site for access to
their secure account information. Once registered, members can log
in to view their benefits and health and wellness information. They
can also access their claim information and manage their health
spending accounts.
Product Information: Individuals looking for insurance can learn
about the Highmark products available in their service area by
selecting the applicable tab: DISCOVER, SHOP, or MEDICARE.
Continued on next page
What Is My Service Area?
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1.2 HIGHMARKS INFORMATIONAL WEBSITES, Continued
Updating your information in the Provider Directory
The Highmark Provider Directory located on each of our public
websites is a fast, easy way for our members to find providers near
their homes or their workplace. And it is a valuable tool that
offers your current and potential patients important details about
your practice, including office location, hours of operation,
parking availability, and nearby public transit information. We
encourage you to take advantage of one of the more unique and newer
features of our online directory the ability to add your
photograph. The inclusion of a photo helps to personalize your
directory listing and can make it easier to market your practice to
potential patients. Your photo can be easily uploaded through
Provider File Management in NaviNet. For complete instructions for
uploading your photo, click on the Tip Sheet link above. If you
determine that your information is inaccurate in the online
directory, you can conveniently update the information online
through NaviNet. Select Provider File Management from the main menu
on Highmarks Plan Central in NaviNet. Provider Directory
Information: Providers acknowledge that the information listed in
any Highmark provider directory, including, but not limited to,
name, contact information, description of services, photographs,
demographics, and other information, may also be listed in any Blue
Cross Blue Shield Association (BCBSA) and/or other BCBSA
independent licensee Plan provider directories, as determined by
Highmark.
Tip Sheet
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1.2 THE PROVIDER RESOURCE CENTER
Overview The Provider Resource Center is a repository of
pertinent reference materials. This
special section of our websites is specifically dedicated to
providers and contains lots of helpful information and resources to
help in your daily interactions with Highmark members and with
Highmark. We encourage you to bookmark the site and take advantage
of this convenient reference tool.
Accessing the Provider Resource Center
The Provider Resource Center is available on our regional public
websites by choosing the Provider Resource Center link under
Helpful Links on the home page. Access to the Provider Resource
Centers for all service areas is also available at highmark.com.
Click on the CONSUMERS/MEMBERS/ PROVIDERS button. And then select
the link for the Highmark plan in your service area from the
options under the FOR PROVIDERS heading (see image on page 3 of
this unit). You can click on the links below to access the Provider
Resource Center applicable to your service area through our public
websites.
PA Central, Eastern, and Northeastern Region Provider Resource
Center PA Western Region Provider Resource Center Delaware Provider
Resource Center West Virginia Provider Resource Center
For your convenience, the Provider Resource Center is also
available to you on NaviNet. Additional information not accessible
on the public websites is available in the Provider Resource Center
via your secure NaviNet logon.
Quicklinks
The Quicklinks feature on the Provider Resource Center provides
faster access to the information you use the most, including the
Highmark Blue Shield Office Manual. Click on the down arrow, and
then select from the available options.
Continued on next page
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1.2 THE PROVIDER RESOURCE CENTER, Continued
Search feature
The Provider Resource Center features a search tool to assist
you in finding the information you need. Enter your keyword(s) in
the search box available at the top of the menu, and then click on
the search icon. The search results will include all information
available on your topic in the Provider Resource Center. The Whats
This? link below the search box details advanced search options for
a more successful search.
What you can find on the Resource Center
The Provider Resource Center contains information including, but
not limited to: Important announcements and updates Current and
archived newsletters Recent and archived mailings Radiology
Management Program BlueCard Clinical Reference Materials Provider
manuals Online Provider Training Medical and Claims Payment
Guidelines Pharmacy/Formulary information EDI Services Real-Time
Tools Health Equity and Quality Services And much more!
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1.2 NAVINET AUTOMATED INQUIRIES AND TRANSACTIONS
NaviNet NaviNet is an Internet-based application for providers
to streamline data
exchanges between their offices and Highmark. This service is
available at no cost to network participating providers. NaviNet
gives users real-time access to Highmark's membership, claims, and
provider and payment systems, making your job easier. NaviNet
seamlessly integrates all insurer-provider transactions into one
system, such as inquiries on referrals/authorizations, eligibility,
benefits, claims status, claims investigations, procedure/diagnosis
codes, and provider/facility searches. NaviNet can also be used for
claims submissions, authorization requests, and provider
information changes. NaviNet provides access to Highmarks tools for
real-time claim estimation and adjudication. Our Provider Resource
Center is also accessible through NaviNet. NaviNet is the preferred
Highmark tool for inquiring about member information.
NaviNet-enabled providers are expected to use this tool for all
routine eligibility, benefit, and claim status inquiries. Practices
must use NaviNet for routine inquiries that can easily be answered
online. The expertise of the Provider Service staff will remain
available for non-routine inquiries that require analysis and/or
research.
Not yet NaviNet-enabled?
If you are a provider who participates with Highmark and are
interested in or want more information about NaviNet, please
contact Highmark Provider Services. You can also visit the NaviNet
website at navinet.net and enroll by clicking on the PROVIDERS:
SIGN UP FOR NAVINET button.
Enrollment in NaviNet required for all participating
providers
In support of the Health Information Technology for Economic and
Clinical Health (HITECH) Act of 2009, Highmark has taken steps to
eliminate paper transactions with our contracted practitioners. All
new assignment accounts are required to enroll in NaviNet. Once
enrolled in NaviNet, providers are also required to enroll to
receive Electronic Funds Transfer (EFT) and paperless Explanation
of Benefits (EOB) statements. For more information, please see the
manuals Chapter 2, Unit 1: How to Participate in Highmarks
Networks.
Continued on next page
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HIGHMARK BLUE SHIELD OFFICE MANUAL | CHAPTER 1.2 9 | P a g e
1.2 NAVINET AUTOMATED INQUIRIES AND TRANSACTIONS, Continued
Advantages of using NaviNet
NaviNet is an easy online solution that links physician offices
with Highmark and other health plans. The benefits of using
NaviNets online service include:
Eliminates waiting in a call queue (on hold). Has no limit to
the number of issues you can research online. Presents information
for all Highmark-supported product lines, including
traditional indemnity, managed care, Medicare Advantage (PA and
WV only), and the Federal Employee Program (FEP).
Presents the most current information on Highmarks systems. What
you view on your screen is the same information Highmark staff
views when they talk to you on the phone.
Has extended hours of availability: Monday through Friday from 5
a.m. to 3 a.m. Saturday from 5 a.m. to 11 p.m. Sunday from 5 a.m.
to 9 p.m.
NaviNet Support: User Guides
If your staff requires training or a refresher course on how to
use any of the NaviNet applications, please direct them to NaviNet
Support. It is accessed by clicking on Help on the toolbar at the
top of the screen on Highmark Plan Central.
A new window will then open for NaviNet Support. Under Health
Plans, select the applicable Highmark option for your service area
from the dropdown, and then click on the Go button. You will then
be directed to NaviNets easy-to-use training modules called User
Guides.
NaviNet Support: FAQs and Case Management System
Before you contact NaviNet with a question, please see if it has
been answered in NaviNets Frequently Ask Questions. You can find
these FAQs by clicking on Help in NaviNet, and then selecting the
Contact Us tab on the NaviNet Support page.
The best way to contact NaviNet is by opening a case. NaviNets
case management system provides a central place for you to track
any issues you may have with NaviNet. In NaviNet, select My
Account, and then click Open a Case.
NaviNet Support: Live Customer Service
If you prefer to speak to a NaviNet Customer Service
representative directly, live NaviNet Customer Service is available
by calling:
1-888-482-8057 (TDD/TTY: 1-800-480-1419)
Hours of availability are Monday through Friday from 8 a.m. to
11 p.m. ET and Saturday from 8 a.m. to 3 p.m. ET.
Continued on next page
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1.2 NAVINET AUTOMATED INQUIRIES AND TRANSACTIONS, Continued
If NaviNet is not available
Highmark encourages all providers to use NaviNet for convenient,
accurate, and timely information on eligibility and benefits, as
well as claim status and a wide variety of other helpful
information including authorizations, claim investigations, medical
policy, practice information updates, and more. Providers can
continue to call Provider Services for assistance if they do not
yet have access to NaviNet or when NaviNet is not available. Please
use the Provider Services phone number applicable to your service
area:
PA Western Region: 1-800-547-3627 PA Central and Northeastern
Regions: 1-866-731-8080 Delaware: 1-800-346-6262 West Virginia:
1-800-543-7822
What Is My Service Area?
Why blue italics?
https://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-how-to-use.pdf
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1.2 PROVIDER PUBLICATIONS
Overview Highmark regularly releases publications as part of our
commitment to keep the
provider community informed. One of the most important ways
Highmark communicates with all providers is through our two
newsletters Provider News and Medical Policy Update. In addition,
the Clinical Views journal is targeted directly to physicians and
clinicians.
Provider News
Provider News is Highmarks bimonthly informational newsletter
for health care professionals and facilities, and their office
staffs, who participate in our networks and submit claims to
Highmark using the 837P/837I HIPAA transactions or 1500/ UB-04
claim forms. Provider News contains the information that providers
need to know to keep them informed of key developments at Highmark.
In its six issues a year, this newsletter conveys important product
and administrative news including billing, claims, and program
updates. Provider News also offers tips and reminders, and it
provides information about Highmark tools and resources. This
publication may also contain administrative requirements, policies,
procedures, or other similar requirements of Highmark that are
binding upon Highmark and its contracted providers. Current and
past issues of Provider News (and its predecessors) are always
available online under Publications and Mailings on the Provider
Resource Center. You can access the Provider Resource Center
through NaviNet or by selecting Provider Resource Center on the
home page of Highmarks regional public websites (under Helpful
Links).
Medical Policy Update
Medical Policy Update, introduced in January 2015, is a monthly
newsletter that provides information for most health care
professionals and facilities participating in our networks. It
focuses exclusively on upcoming medical policy and claims
administration updates (including coding guidelines and procedure
code revisions), and is the sole source for this information. It is
important for all participating providers and their office staffs
to review each issue of Medical Policy Update. This publication
serves as one of Highmarks official notifications of new and
revised policies and procedures. You can find current and past
issues of Medical Policy Update under Publications and Mailings on
the Provider Resource Center.
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1.2 PROVIDER PUBLICATIONS, Continued
Medical Policy Update (continued)
Note: All previous notifications for medical policy updates
prior to 2015 are retained on the Provider Resource Center. These
can be found under Publications and Mailings as follows:
In Pennsylvania, see Policy, Review and News (PRN). In Delaware,
select the link for Special Bulletins & Mailings. In West
Virginia, select the link for Provider News. Medical Policy
updates
were communicated in the Special Editions of Provider News.
Distribution of provider newsletters
Distribution of all provider newsletters is primarily
electronic. We publish all issues of the newsletters online in the
Provider Resource Center under Publications and Mailings. Current
and past issues of Provider News and Medical Policy Update (and
their predecessors) are always available on the Provider Resource
Center.
You may also sign up through e-Subscribe for electronic
notification via email. Please review the section later in this
unit about signing up for our convenient e-Subscribe notification
option.
If you require a paper copy of the newsletter, please contact
the Provider Service Center.
Clinical Views
Clinical Views is a clinical journal published by Highmark for
network physicians and other patient care professionals. Clinical
Views is one of our best ways to communicate directly with
physicians and clinicians about topical health issues, highlight
the many talented medical experts in Highmarks various regions, and
share best practices. It is filled with information on Highmarks
quality initiatives, condition management programs, prescription
drug news, and much more.
This informative journal provides updates on Highmarks clinical
quality programs, tools, resources, and initiatives. It also
includes physician profiles as a way of sharing best practices. In
addition, opportunities are offered for obtaining Continuing
Medical Education (CME) credits. Clinical Views is printed and
mailed to network providers. Current and archived issues of
Clinical Views are also available under Publications and Mailings
on the Provider Resource Center. E-Subscribe electronic
subscription of Clinical Views is not available at this time.
What Is My Service Area?
https://www.highmark.com/health/pdfs/hbsom-map.pdf
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1.2 SPECIAL BULLETINS AND MAILINGS
Overview In addition to our regular publications, Highmark uses
special mailings to inform
providers of changes to Highmark policies and procedures,
updates to the formulary and authorization list, upcoming
initiatives, and much more. Special mailings are intended to be a
companion to Highmarks regularly scheduled periodicals.
Special mailings are used when we want to communicate
information quickly, when the information is too complicated or
lengthy to include in the newsletters, or when the information
pertains to a limited group of providers or to a specific service
area.
These communications from Highmark may be delivered to providers
in any of the following formats:
Special Bulletins and Special eBulletins* Letters Brochures Fact
sheets Postcards Flyers included with checks and/or Explanation of
Benefits
Because Special Bulletins and other mailings contain important
information about specific claims and coverage issues that could
affect your practice, we hope you will take time to read them and
retain them for future reference. * Special eBulletins are
published electronically only on the Provider Resource Center.
Distribution of Special Bulletins
Special Bulletins are printed and mailed to network providers in
Pennsylvania and West Virginia. In Delaware, Special Bulletins are
delivered to network providers via fax.
Also available online!
Our mailings and Special Bulletins can also be found on our
Provider Resource Center. Select Publications and Mailings from the
main menu, and then click on Special Bulletins & Mailings.
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1.2 SPECIAL BULLETINS AND MAILINGS, Continued
Electronic delivery of select Special Bulletins
By signing up for e-Subscribe, select network-wide Special
Bulletins can be delivered right to your email inbox, keeping you
up-to-date on the most current notifications as soon as they are
available. Please review the next section of this unit about
signing up for our convenient e-Subscribe notification option.
IMPORTANT NOTE: Email subscriptions for Special Bulletins are for
network-wide publications only; mailings targeted to specific
specialties or regions will not be distributed via e-Subscribe.
When you sign up for e-Subscribe, you will continue to receive
Special Bulletins in the postal mail in Pennsylvania and West
Virginia and via fax in Delaware. And all Special Bulletins will
continue to be published to the Provider Resource Center, which is
easily accessed through NaviNet and also our public websites.
What Is My Service Area?
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1.2 E-SUBSCRIBE
e-Subscribe The e-Subscribe feature available on the Provider
Resource Center allows you to
subscribe to electronic notification of various online
publications and information updates. The latest Highmark news and
updates arrive in your email inbox with timely, up-to-date
information at your fingertips. Your e-Subscribe subscription
provides you with electronic delivery of publications and
communications specific to your provider type. Professional
providers will receive prompt delivery of the latest Provider News
and Medical Policy Update newsletters and select Special Bulletins.
In addition, you will receive monthly notifications of updates to
the Highmark Blue Shield Office Manual.
Sign up now!
Sign up for e-Subscribe today to stay informed of the latest
news at Highmark. To subscribe to receive free email notifications
with newly released publications or information updates, select
e-Subscribe on the Provider Resource Center, and then click on the
e-Subscribe for Publications and Notifications link. Enter the
required information on the online form and select the applicable
provider type Professional Provider (837P & 1500 billers)
and/or Facility/Institutional (837I & UB04 billers). Once you
have completed the form, click on the Subscribe button at the
bottom of the page. You will receive a confirmation message
immediately when your subscription is successfully submitted. The
emails will be delivered to you from [email protected].
To ensure delivery of the emails, please add the email address to
your address book. By subscribing, you agree to electronically
receive administrative requirements that are legally binding upon
contracted providers and upon Highmark. By doing this, you
acknowledge that such communications and publications will be sent
only by electronic means to the email address you provide. Please
maintain such electronic publications in the event of future
questions and to ensure such compliance. You may unsubscribe from
this list at any time on future emails from Highmark.
Publications always available on the Provider Resource
Center
Electronic copies of Provider News, Medical Policy Update, and
Special Bulletins are always available under Publications and
Mailings on the Provider Resource Center through NaviNet or via
Highmarks public websites. Both current and past issues of all
publications are available online for your convenience.
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1.2 PROVIDER SERVICE REPRESENTATIVES
Overview Immediate answers to most inquiries can be found by
using NaviNet -- the
preferred method for benefit and claim inquiries. For more
complex issues or if NaviNet is unavailable, Provider Service
representatives are available to answer questions and also provide
information about Highmark programs.
Contact information and availability
PA WESTERN REGION: Please contact the Provider Service
department at 1-800-547-3627. Hours of operation are 8 a.m. to 5
p.m. EST, Monday through Friday.
For Medicare Advantage, please use the following toll-free
numbers: Freedom Blue PPO: 1-866-588-6967 Security Blue HMO
(Western Region only): 1-866-517-8585 Community Blue Medicare HMO:
1-888-234-5374
PA CENTRAL AND NORTHEASTERN REGIONS: Please contact the Provider
Service department at 1-866-731-8080. Hours of operation are 8 a.m.
to 5 p.m. EST, Monday through Friday.
For Medicare Advantage, please use the following toll-free
number: Freedom Blue PPO: 1-866-588-6967 Community Blue Medicare
HMO: 1-888-234-5374
PA EASTERN REGION: Please contact the Provider Service
department at 1-866-975-7290. Hours of operation are 9 a.m. to 12
noon, and then from 1 p.m. to 4:30 p.m. EST, Monday through Friday.
DELAWARE: Please contact the Provider Service department at
1-800-346-6262. Hours of operation are 8:30 a.m. to 5 p.m. EST,
Monday through Friday.
WEST VIRGINIA: Highmark West Virginia Provider Service:
1-800-543-7822
Hours of operation are from 8 a.m. to 5 p.m. Monday through
Friday Highmark Senior Solutions Company Medicare Advantage Freedom
Blue
PPO: 1-888-459-4020. Hours: 8 a.m. to 8 p.m. Monday through
Sunday.
Before you call
When placing a call to Provider Services, please have all
necessary information available including:
Patients name, Member ID, and group number; If available, the
type of services and dates the services were performed; Claim
number (taken from the Explanation of Benefits); and The providers
name and provider number.
What Is My Service Area?
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CHAPTER 2: PROVIDER PARTICIPATION AND RESPONSIBILITIES
UNIT 1: HOW TO PARTICPATE IN HIGHMARKS NETWORKS
IN THIS UNIT
TOPIC SEE PAGE Introduction to Network Participation 2 How to
Register with Highmark 7 Professional Provider Networks:
Pennsylvania 8 Delaware 11 West Virginia 12
Select DME Network (PA ONLY) 13 How to Become a Participating
Provider (PA ONLY) 14 How to Participate in Highmarks Credentialed
Networks 16 Requesting a Contract Copy 19 How to Resign From
Network Participation 20 Dual Networks (PA ONLY) 21 Assignment
Accounts 22 Provider Tax Identification Numbers 26 Electronic
Transaction Requirements 27 Non-Network Provider Payment Guidelines
30 National Provider Identifier (NPI) 31 Facility and Ancillary
Providers UPDATED! 32 Blue Distinction 34
What Is My Service Area?
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2.1 INTRODUCTION TO NETWORK PARTICIPATION
Overview Highmark pays claims for services performed by
licensed, eligible health care
professional providers. Eligible providers may sign an agreement
to participate in one or more of Highmarks professional provider
networks. Providers who choose not to participate in Highmarks
networks must register with Highmark prior to submitting claims for
covered services. As a participant in any of Highmarks networks,
professional providers agree to provide services to Highmark
members according to the terms of their agreement, the regulations
that outline their obligations to Highmark members, and any
relevant administrative requirements. Although they do not sign an
agreement with Highmark, non-network providers are required to
accurately report services performed and fees charged. All
providers who submit claims to Highmark must obtain an individual
National Provider Identifier (NPI) number. Highmark will only make
payments for eligible services rendered by a provider with a valid
NPI. To learn more about obtaining an NPI, please see the section
in this unit titled National Provider Identifier (NPI).
Non-discrimination policy
In selecting and credentialing providers for the associate
networks, Highmark does not discriminate in terms of participation
or reimbursement against any health care professional who is acting
within the scope of their license or certification. In addition,
Highmark does not discriminate against professionals who serve
high-risk populations or who specialize in the treatment of costly
conditions. If Highmark declines to include a provider in its
networks, Highmark will furnish written notice of the reason for
its decision to the affected provider.
Who is an eligible provider?
Eligible professional providers include:
Doctors of Medicine (MD) Certain certified registered nurses
Doctors of Osteopathy (DO) Licensed audiologist Doctors of
Dentistry (DDS/DMD) Licensed speech-language pathologist Doctors of
Podiatry (DPM) Licensed clinical social workers Doctors of
Optometry (OD) Licensed occupational therapists Doctors of
Chiropractic (DC) Licensed marriage and family therapists Nurse
midwives Licensed professional counselors Licensed physical
therapist Licensed dietitian nutritionist Licensed psychologist
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2.1 INTRODUCTION TO NETWORK PARTICIPATION, Continued
Additional providers eligible in WV
Highmark West Virginia also contracts with the following
provider types: Acupuncturists Massage therapists Certain diabetic
educators
Mid-level providers
Mid-level providers who are not eligible to participate in
Highmarks participating provider and credentialed networks may be
eligible to contract with Highmark to provide services for certain
government programs only ( i.e., Federal Employees Program [FEP]
and Medicare Advantage) as follows:
FEP: Acupuncturist Medicare Advantage: Physician assistant
Practitioners who may serve as PCPs
A physician (MD or DO) who is a family practitioner, general
practitioner, internal medicine practitioner, or pediatrician is
entitled to participate as a primary care physician (PCP). The
physician must complete the credentialing process. In addition,
certified registered nurse practitioners (CRNPs) have the
opportunity to offer their clinical expertise as a primary care
CRNP to Highmark members. Qualified CRNPs must complete a
credentialing application and meet credentialing requirements to
receive designation as a primary care CRNP with Highmark. CRNPs who
receive primary care CRNP designation with Highmark can only
participate in Highmarks provider networks in that capacity; they
cannot serve as both a CRNP specialist and a primary care
provider.
Practitioner availability monitoring
Since Highmark requires members to utilize a designated
practitioner network, Highmark must ensure that there are adequate
numbers and geographic distribution of primary care, behavioral
health, and specialty care practitioners to meet member needs.
Highmark monitors practitioner availability annually against its
standards and initiates action, as needed, to improve member access
to covered services. Practitioner availability monitoring is
completed for primary care practitioners, high volume specialty
care practitioners, and behavioral health practitioner types. All
behavioral health practitioner types (not just high volume types)
are assessed on an annual basis.
Continued on next page
What Is My Service Area?
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2.1 INTRODUCTION TO NETWORK PARTICIPATION, Continued
General conditions of participation
In order to participate in Highmarks networks, a provider must:
Execute the appropriate network participation agreement(s),
which
include the terms of payment, and complete fully any required
application or information forms;
Abide by the terms and conditions of such agreement(s),
including any amendments;
Satisfy and remain in compliance with applicable Highmark
credentialing and re-credentialing standards;
Cooperate and comply with Highmarks health services management
programs, including but not limited to: pre-certification, prior
authorization, care and case management, disease management,
clinical quality improvement, and other programs and initiatives
that maybe adopted;
Provide timely written responses to complaints or clinical
quality issues upon request from Highmark;
Follow Highmarks appeals processes and other dispute resolution
mechanisms; and
Adhere to Highmarks billing, claims submission, an