First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.Your session is about to expire! Click the button below to extend your session and stay logged in. You will be logged out after 5 more minutes of inactivity.MEDICAID REDETERMINATION. ACA/CHIP Provider Flyer for Medicaid Redetermination. Last updated on 2/7/2024 2:21:17 PM.Short-Acting Opioid Prior Authorization Form. Specialty Drug Request Form. Sunosi Prior Authorization Form. Testosterone Product Prior Authorization Form. Transplant Rejection Prophylaxis Medications. Vyleesi Prior Authorization Form. Weight Loss Medications Request Form. Last updated on 1/23/2024 5:32:02 PM. Contact Us.Availity Essentials: Introduction for Highmark Providers. Applications covered: General Navigation, Eligibility and Benefits Inquiry, Manage My Organization, Payer Spaces, and Authorizations. ... As more information becomes available about the status of Risk Manager, we will share that with you via the Provider Resource Center and Availity portal.The program will serve as a foundational value-based reimbursement program for Highmark's Physical and Occupational Therapy provider networks. The program offers the potential for significant value-based reimbursement by rewarding participants for managing their Highmark member patient population toward high value (both quality and efficiency ...Provider data changes can be made by visiting the provider portal or by using the Provider Information Management Forms section of the Provider Resource Center. After you submit your form successfully, Highmark will retain an electronic copy of your CAQH ProView profile in its database and will send you a confirmation email.Tool and Resources - The Provider Resource Center (PRC) is the central location for helpful information such as: The Highmark Provider Manual. BlueCard (Chapter 2, Unit 6) Fraud Prevention (Chapter 6, Unit 8) Important Announcements and Updates. Prior Authorization Requirements.Provider Directory. Site Map. Legal Information. The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc ...It's about convenience and quality. That's why we constantly work to identify high-performing providers and offer access to alternative care locations such as clinics, local facilities, and in-home care. To that end, Highmark has measured a specific set of performance metrics for components of care provided by participating home health agencies.First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.Medical Policy Update is a monthly newsletter for the health care providers who participate in our networks and submit claims to Highmark using the appropriate HIPAA transactions or claim forms as required by Highmark.This publication focuses only on medical policy and claims administration updates, including coding guidelines and procedure code revisions, and is the sole source for this ...If a prior authorization is required, please submit the information below to the Highmark Prior Authorization Department by faxing to 1-866-240-8123. Member name, DOB, ID#. Drug, strength, quantity requested. Diagnosis, alternatives tried. Other pertinent clinical information (to view the criteria, please access our pharmacy clinical policies ...Highmark's Provider Resource Center (PRC) - the main hub for important information, including policies, procedures, the Highmark Provider Manual, and Provider News. Interactive Voice Response (IVR) System - The Provider Service Center offers options for you to access information, such as claim status or member benefits, without a live agent.In 2.6 NAIC Codes, New York state information was added, including NAIC Code 55204, as well as claim submission procedures for Empire/Anthem and Excellus members when treated by Highmark providers. Chapter 6, Unit 1: General Claim Submission Guidelines. In 6.1 Timely Filing Requirements, the NEW YORK TIMELY FILING POLICY section was updated.Assistance for Highmark Participating Providers Impacted by Change Healthcare Cyber Event. 3/11/2024.Tool and Resources – The Provider Resource Center (PRC) is the central location for helpful information such as: The Highmark Provider Manual. BlueCard (Chapter 2, Unit 6) Fraud Prevention (Chapter 6, Unit 8) Important Announcements and Updates. Prior Authorization Requirements.First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.Introducing a new provider resource experience that simplifies getting you the information you need, when you need it. ... Message Center. Manuals . Highmark Provider Manual; ... Quick Claims Functionality in Availity Now Available for Highmark Providers. 4/17/2024. National Infant Immunization Week is April 22-29.NaviNet. NaviNet's Quick Start Guide — available on the Provider Resource Center — has step-by-step procedures for conducting both claim status inquiries and claim investigations. The guide features easy-to-follow instructions accompanied by screenshots showing users what to do during each step. The Claim Status Inquiry function allows you to view real-time, detailed claim information ...Authorization Forms. Bariatric Surgery Precertification Worksheet. Behavioral Health (Outpatient - ABA) Service Authorization Request. Home Health Precertification Worksheet. Inpatient and Outpatient Authorization Request Form. Pharmacy Prior Authoriziation Forms. Last updated on 12/19/2023 10:06:35 AM.Highmark Provider Forms. Authorization. Access precertification worksheets, requests for surgical services, and more. FIND FORMS. Pharmacy Authorization. View a variety of …Highmark Blue Shield welcomes newly contracted providers in Southeastern Pennsylvania. To help you get acquainted with working together, we offer tools and resources through our Provider Resource Center (PRC). The Highmark PRC is the central location for helpful information such as: The Highmark Provider Manual. …Credentialing information for new providers can be found in the Credentialing section of the Provider Resource Center in the left-hand menu or by clicking HERE. Scroll down on the page to find specific information for Behavorial Health providers. Additional information on Credentialing is available in Chapter 3 of the Highmark Provider Manual.The benefits of providing both members and providers with the efficiency and safety of virtual health are here to stay. Virtual health services mean the use of synchronous or asynchronous telecommunications technology by a health care practitioner to provide health care services, including, but not limited to: Assessment. Diagnosis. Consultation.Step 1: Highmark Training. Step 2: Medicare Parts C and D General Compliance Training. Step 3: Combating Medicare Parts C and D Fraud, Waste and Abuse. Step 4: Training Attestation. Once you meet the program requirements, an authorized representative of your organization can complete and retain a copy of the attestation form above for your records.Provider data changes can be made by visiting the provider portal or by using the Provider Information Management Forms section of the Provider Resource Center. After you submit your form successfully, Highmark will retain an electronic copy of your CAQH ProView profile in its database and will send you a confirmation email.Behavioral Health Resources. Behavioral Health Telemedicine and Virtual Visits. Enhanced Community Care Management Program. Laboratory Management Program. Musculoskeletal Surgery and Interventional Pain Management Services Prior Auth Program. Physical Medicine Management. Post-Acute Care Management For Medicare Advantage Members.Provider data changes can be made by visiting the provider portal or by using the Provider Information Management Forms section of the Provider Resource Center. After you submit your form successfully, Highmark will retain an electronic copy of your CAQH ProView profile in its database and will send you a confirmation email.Each reimbursement policy includes information pertaining to all Highmark markets as indicated in the header, with state specific variations indicated within the policy bulletin. History versions of reimbursement policies are stored within the PDF files. Click the "View History" link on the first page of the policy to view previous versions.New Fax Number: (833) 559-2857. Access the new fax cover page here. Providers will no longer be able to submit authorization requests by email after 4/30/24, as the [email protected] email address will be disabled. In addition, the Adagio fax number (412) 201-4701 will no longer be active after 4/30/24.Highmark will also post communications here on the Provider Resource Center, and Availity may announce new features and training opportunities on their in-portal message center. For Help. For Availity Client Services assistance, call 1-800-AVAILITY (282-4548) or, within the Availity portal, click Help & Training and then click on Availity …PRESCRIPTION DRUG MEDICATION REQUEST FORM FAX TO 1-866-240-8123. To view our formularies on-line, please visit our Web site at the addresses listed above. Fax each form separately. Please use a separate form for each drug. Print, type or write legibly in blue or black ink. See reverse side for additional details.eviCore performs utilization management for MSK surgical procedures and IPM services for Highmark's fully insured Commercial, Medicare Advantage, and Affordable Care Act members. Highmark manages prior authorizations for MSK surgeries or IPM services for all other members according to the member's benefits.Highmark will also post communications here on the Provider Resource Center, and Availity may announce new features and training opportunities on their in-portal message center. For Help. For Availity Client Services assistance, call 1-800-AVAILITY (282-4548) or, within the Availity portal, click Help & Training and then click on Availity Support.Highmark will also post communications here on the Provider Resource Center, and Availity may announce new features and training opportunities on their in-portal message center. For Help. For Availity Client Services assistance, call 1-800-AVAILITY (282-4548) or, within the Availity portal, click Help & Training and then click on Availity Support.Attached please find the following documents to help you start the credentialing process: Initial Application for Facility and Ancillary Providers. Organizational Provider Participation, Credentialing, and Contracting Requirements. Highmark Provider Manual Chapter 3, Unit 4. Health Options (Medicaid) Forms (Recommended forms for Delaware Health ...For more information about the Copay Armor program, contact the Highmark Provider Service Center for your service area. Free Market Health. Free Market Health is a new innovative specialty pharmacy model that aligns resources, risk, and accountabilities for pharmacy referrals and reimbursement. 5 Tips for Faxing Pharmacy Prior Auth Requests.Provider data changes can be made by visiting the provider portal or by using the Provider Information Management Forms section of the Provider Resource Center. After you submit your form successfully, Highmark will retain an electronic copy of your CAQH ProView profile in its database and will send you a confirmation email.Issue 2. Provider Resource Center Provides Answers at Your Fingertips. Issue 1. Reporting Requirements for Facility Mergers, Acquisitions and Changes. Issue 1. Successful Discharge Planning in Skilled Nursing Facilities. Issue 1. Highmark Skilled Nursing Facility Pay for Value Program. Issue 1.July 2022. Pennsylvania HealthChoices (PHC) Special Enrollment Period. July 2022. Notice of Medicaid Policy Updates for Aug 1. July 2022. Authorization Requirements Medicare - Jul 1. June 2022. Provider Webinars: 2022 Annual Provider Education. June 2022.Return to: Provider Data Services PO Box 890146 Camp Hill, PA 17001-9748 FAX: 800-236-8641 Highmark Enhanced Provider Information MNT TR Please fill out the applicable information below and submit your completed form to Highmark. BS ID: _____ Name: Location:Medicaid Resource Center Medicare Resource Center ... For questions or information regarding general policy and procedures, contact a Highmark Wholecare provider representative at: Medicaid 1-800-392-1147, Medicare Assured 1-800-685-5209. Representatives are available 8 a.m. to 4:30 p.m., Monday - Friday. ...Provider Resource Center. Credentialing - New York Providers. Credentialing policy information for new providers who are credentialing with Highmark Blue Cross Blue …In today’s competitive business landscape, customer service plays a crucial role in the success of any organization. One way to ensure exceptional customer service is by outsourcin...Provider News. Provider News is a valuable resource for health care providers who participate in our networks. Published monthly on the last Monday of the month, Provider News conveys important product, policy, and administrative information, including billing, claims, and program updates. The publication also features the latest news ...All physical medicine providers must meet or exceed all the defined metrics listed below to be included in the program and achieve Qualifying status. • Total volume of Care Registration and Care Authorization requests should be equal to or greater than 20 between dates of service June 1 and May 31. • Care Authorization Approval Rate equal ...In today’s fast-paced world, healthcare providers are constantly looking for ways to improve patient satisfaction and enhance the overall patient experience. One key area where imp...A Highmark Wholecare representative will contact the member and follow-up with the provider at the provider's request. For more information or to request member outreach, please call Highmark Wholecare's Case Management Department at 1-800-392-1147. You can also fax the Member Outreach Form to the Case Management Department at (888) 225-2360.Availity Essentials: Introduction for Highmark Providers. Applications covered: General Navigation, Eligibility and Benefits Inquiry, Manage My Organization, Payer Spaces, and Authorizations. ... As more information becomes available about the status of Risk Manager, we will share that with you via the Provider Resource Center and Availity portal.Rate Change: Five Drugs in the Medical Injectable and Site of Care HIT Programs. 5/3/2024. New Inpatient Facility Diagnosis Guidelines Available on PRC via Availity. …Home Health/Home Infusion Therapy/Hospice: 888-567-5703. Inpatient Clinical: 800-416-9195. Medical Injectable Drugs: 833-581-1861. Musculoskeletal (eviCore): 800-540-2406. Telephone: For inquiries that cannot be handled via the online provider portal, call the appropriate Clinical Services number, which can be found here.Care Management Programs. Advanced Imaging and Cardiology Services Program. Behavioral Health Resources. Behavioral Health Telemedicine and Virtual Visits. Laboratory Management Program. Musculoskeletal Surgery and Interventional Pain Management Services Prior Auth Program. Physical Medicine Management. Radiation Therapy Authorization Program.Following is the update to the Highmark Drug Formularies and pharmaceutical management procedures for December 2022. The formularies and pharmaceutical management procedures are updated on a bi-monthly basis, and the following changes reflect the decisions made in December by our Pharmacy and Therapeutics Committee.Behavioral Health Provider Toolkit Overview. In alignment with the mission and values of Highmark Wholecare, promoting Wholecare which is a whole health model of care in which an individual's health and well-being is supported across behavioral, physical, and environmental factors. Highmark Wholecare is committed to promoting integrated care ...Follow this link to access the CAQH. ( Previously referred to as the Universal Provider Datasource.) Under Provider Sign In, enter your username and password if registered, or select register now. Enter your CAQH Provider ID. (If you don't know it, call CAQH at 1-888-599-1771). Enter or update your information.This information is issued on behalf of Highmark Blue Shield and its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. ... see Highmark Delaware's online Provider Resource Center and access the . Pharmacy Program/Formularies. link for details on the formularies and formulary options that ...Introducing a new provider resource experience that simplifies getting you the information you need, when you need it. You're invited to visit an early release of our new site; try it out at providers.highmark.com.Your feedback is appreciated as we work to complete the experience.Highmark continually seeks ways to make its network credentialing process easier for our providers. Find the information and forms you'll need to get your organization credentialed.Medicaid Resource Center ... here\u003c/a\u003e to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and ...First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross …Attention CHIP Providers:CHIP Resources Available On the Provider Resource Center. We've added the following resources to the Provider Resource Center for providers who participate in the Pennsylvania Children's Health Insurance Program (CHIP). Highmark CHIP Gap Report: a monthly report Highmark will produce beginning March 2020. The report.Highmark's Living Health strategy aims to promote patient care that is personal, simplified, and proactive, while reducing your administrative burden. We want to empower patients to be more engaged with their everyday health, so they can achieve improved outcomes and greater well-being. Please recommend that your eligible patients enroll in ...Published March 28, 2022. Following is the update to the Highmark Drug Formularies and pharmaceutical management procedures for January 2022. The formularies and pharmaceutical management procedures are updated on a bi-monthly basis, and the following changes reflect the decisions made in January 2022 by our Pharmacy and Therapeutics Committee.Highmark Provider Manual. We have redesigned the Highmark Provider Manual to make it easier for you to view and find important information, policies, and procedures for all providers participating in our networks in Delaware, New York, Pennsylvania, and West Virginia. The Highmark Provider Manual is your primary reference guide to Highmark.Providers may provide information to Highmark to establish a rationale for not following the protocols. To request a review, submit a . Provider Pathways Reconsideration Request Form, which is available on the Highmark Provider Resource Center. Select . CARE MANAGEMENT PROGRAMS. from the main menu on the left, and then . Physical Medicine ...Home Health/Home Infusion Therapy/Hospice: 888-567-5703. Inpatient Clinical: 800-416-9195. Medical Injectable Drugs: 833-581-1861. Musculoskeletal (eviCore): 800-540-2406. Telephone: For inquiries that cannot be handled via the online provider portal, call the appropriate Clinical Services number, which can be found here.Tool and Resources – The Provider Resource Center (PRC) is the central location for helpful information such as: The Highmark Provider Manual. BlueCard (Chapter 2, Unit 6) Fraud Prevention (Chapter 6, Unit 8) Important Announcements and Updates. Prior Authorization Requirements.Comcast Center is a walk-in customer service center that provides customers with support and assistance for their Comcast products and services. Whether you’re having trouble with ...The Provider File Management (PFM) tool allows professional providers to view and make changes to their practice information. Changes to your practice information will be updated in real -time. Since Highmark uses this information for member directories and claims processing, it is vitally important that Highmark has the most up-to-date and ...First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.Highmark Provider Form Regulations -Version 1.1 - 1/8/19 1. Assignment Account Regulations . I. Introduction . An assignment account is an account established by Highmark Blue Shield to permit one or more individual providers, practicing together, to direct Highmark Blue Shield payments to an entity other than the individual providers.Change of Ownership (CHOW) Form - This form is for Facility and Ancillary Providers to report any changes in ownership, which may include the Legal Name, Doing Business As name, NPI, or Tax ID information.. 24/7 Coverage Form - 24/7 coverage is a requirement for participation in the Highmark Credentialed networks.Please complete this form to indicate how 24/7 coverage is provided by your ...Chapter 3, Unit 2: Professional Provider Credentialing. In 3.2 Highmark Network Credentialing Policy, the ADVANCED PRACTICE PROVIDER (APP) ENUMERATION section was updated to point providers to Reimbursement Policy 068 (RP-068): Mid-Level Practitioners and Advanced Practice Providers for more information instead of Reimbursement Policy 010 (RP ...The following entities serve central and southeastern Pennsylvania and are independent licensees of the Blue Cross Blue Shield Association: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.Highmark requires authorization of certain services, procedures, inpatient level of care for elective/planned surgeries, and/or Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) prior to performing the procedure or service. The authorization is typically obtained by the ordering provider.For non-routine inquiries that require analysis and/or research, contact Highmark's Provider Services. PENNSYLVANIA: • Western Region: Professional Providers . 800-547-3627; Facilities . 800-242-0514 Hours of Availability: 8 a.m. to 5 p.m. EST, Monday through Friday • Central & Northeastern Regions: Professional Providers . 866-731-8080 ...The following entities serve central and southeastern Pennsylvania and are independent licensees of the Blue Cross Blue Shield Association: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.Provider data changes can be made by visiting the provider portal or by using the Provider Information Management Forms section of the Provider Resource Center. After you submit your form successfully, Highmark will retain an electronic copy of your CAQH ProView profile in its database and will send you a confirmation email.First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield.How Members Use the Home Delivery Service. Members can obtain home delivery forms for maintenance drugs by calling the Member Service telephone number on their ID card, or by calling MedcoHealth directly at: 1-800-903-6228. Once a member places an order, the member's information remains on file.Highmark Wholecare providers are contractually required to participate/adhere to Highmark Wholecare Quality Improvement (QI) Programs, including, but not limited to, complying with the regulations found in Title 28, Chapter 27, §27.21a “Reporting of cases by health care practitioners and health care facilities” of the Pennsylvania Code.Provider-Hospital Affiliation Upload Form - Use this form quarterly to upload your provider/hospital affiliation data. NPI Change Form - In this form you will be able to change your NPI. Out of State Address Change Form for Professional Providers - This electronic form should be used for providers outside of Delaware, New York, …eviCore has a dedicated webpage for Highmark providers, Highmark will also post communications here on the Provider Resource Center, and Availity may an, Standard Rates for medical specialty drugs and injections are reimbursed at the, Highmark will also post communications here on the Provider Resource Center, and Avail, First Priority Health, First Priority Life or Highmark Senior Health Company. Central and , Attached please find the following documents to help yo, eviCore has a dedicated webpage for Highmark providers to conveniently access evide, Tool and Resources – The Provider Resource Center (PRC) is the cen, RP-026 Portable Radiography and ECG Services. A “Related Highma, Gastric Surgery/Therapy/Durable Medical Equipment/Outpatient Procedur, Motorized Wheelchair. Osteogenesis Stimulators. Oxygen., The full fee schedule is available on the Provider Resource Cent, First Priority Health, First Priority Life or Highmark, Call-center agents will ask series of questions to determine co, The full fee schedule is available on the Provider Resource Center., The redesign of the Provider Resource Center is the, First Priority Health, First Priority Life or Highmark Senior Health , Highmark Provider Manual ... Message Center. Manuals . Highmark Prov.