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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

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The HBSOM is binding upon providers and may be supplemented or superseded, in whole or in part, by other Highmark guidance and/or requirements furnished or otherwise made available to providers.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]

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.

APRIL 2017

HIGHMARK BLUE SHIELD OFFICE MANUAL | INTRODUCTION 1 | P a g e

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

APRIL 2017


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

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APRIL 2017


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

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

APRIL 2017


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.


Why blue italics?
https://www.highmark.com/health/pdfs/hbsom-how-to-use.pdf

APRIL 2017


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]

APRIL 2017


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.



APRIL 2017


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.

APRIL 2017


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.


APRIL 2017


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.


APRIL 2017


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.

APRIL 2017


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.

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APRIL 2017


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


Why blue italics?
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APRIL 2017


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


Why blue italics?

APRIL 2017


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


Why blue italics?

JUNE 2016

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

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JUNE 2016


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

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

JUNE 2016


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


https://www.highmark.com/health/pdfs/addresses-west.pdfhttps://www.highmark.com/health/pdfs/addresses-central.pdfhttps://www.highmark.com/health/pdfs/addresses-delaware.pdfhttps://www.highmark.com/health/pdfs/addresses-wv.pdfmailto:[email protected]://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf

JUNE 2016


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




JUNE 2016



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


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


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



https://highmark.co1.qualtrics.com/jfe/form/SV_6hv6PKsBD7zRb1zhttps://highmark.co1.qualtrics.com/jfe/form/SV_6hv6PKsBD7zRb1zhttps://www.highmark.com/health/pdfs/forms/prov-file-maint-request.pdfhttps://www.highmark.com/health/pdfs/forms/prov-file-maint-request.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf

JUNE 2016



Retrospective reviews


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


JUNE 2016


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.



JUNE 2016


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

https://www.novitas-solutions.com/http://www.palmettogba.com/palmetto/providers.nsf/Home_Nhttps://www.highmark.com/health/pdfs/hbsom-map.pdfhttps://www.highmark.com/health/pdfs/hbsom-map.pdf

FEBRUARY 2017


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


FEBRUARY 2017


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

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

FEBRUARY 2017


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.



And then select the plan link for your service area.

Click here.
https://www.highmark.com/hmk2/index.shtmlhttps://www.highmark.com/hmk2/index.shtmlhttps://www.highmark.com/hmk2/index.shtmlhttps://www.highmark.com/health/pdfs/hbsom-map.pdf

FEBRUARY 2017


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.


https://www.highmarkbcbs.com/chmptl/chm/jsp/Splash.do?site=hbcbshttps://www.highmarkblueshield.com/chmptl/chm/jsp/Splash.do?site=pbshttps://www.highmarkbcbsde.com/chmptl/chm/jsp/Splash.do?site=hbcbsdehttps://www.highmarkbcbswv.com/home/https://www.highmark.com/health/pdfs/hbsom-map.pdf

FEBRUARY 2017


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
https://www.highmark.com/health/pdfs/hbsom-tip-sheet-upload-provider-photo.pdf

FEBRUARY 2017


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.


https://www.highmark.com/hmk2/index.shtmlhttps://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

FEBRUARY 2017


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!

FEBRUARY 2017


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.

http://www.navinet.net/https://www.highmark.com/health/pdfs/hbsom-chapter2-unit1.pdfhttps://www.highmark.com/health/pdfs/hbsom-chapter2-unit1.pdf

FEBRUARY 2017


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.



FEBRUARY 2017


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


Why blue italics?

FEBRUARY 2017


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.


FEBRUARY 2017


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.


FEBRUARY 2017


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.


FEBRUARY 2017


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.


FEBRUARY 2017


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.

FEBRUARY 2017


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.


FEBRUARY 2017


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


FEBRUARY 2017


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.



FEBRUARY 2017


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

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