Preventive Health Guidelines and Clinical Practice Guidelines Available Online

Highmark and participating network physicians annually review and update the Preventive Health Guidelines and Clinical Practice Guidelines, which are distributed to the practitioner community as a reference tool to encourage and assist you in planning your patients’ care. To help make the information more accessible and convenient for you, we post the complete set of guidelines online. Just visit highmarkbcbsde.com and click Provider Resource Center under Helpful Links. (NaviNet^® users, simply click on Resource Center from the Plan Central page.) Next, go to Clinical Reference Materials, and then select Clinical Practice and Preventive Health Guidelines.

The Preventive Health Guidelines include:

• adult (under and over 65)
• pediatrics
• prenatal/perinatal

There are Clinical Practice Guidelines for the following conditions/patient needs:

ADHD COPD depression smoking cessation

asthma cholesterol management diabetes substance abuse

stable ischemic heart disease heart failure hypertension osteoporosis

Please ask your clinical support staff to bookmark this web page as a handy reference tool to help plan your patients’ care. To obtain a paper copy of the guidelines, write to:

Highmark
Barb Cole, Director, Accreditation and Compliance
Fifth Avenue Place
120 Fifth Avenue, Suite P4425
Pittsburgh, PA 15222

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Appropriate Utilization Decision-Making

Highmark makes utilization review decisions based only on appropriateness of care and service and the existence of coverage. In addition, Highmark does not specifically reward practitioners, providers, Highmark employees or other individuals conducting utilization review for issuing denials of coverage or service, nor does it provide any financial incentives to utilization management decision-makers to encourage denials of coverage.

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Request for Criteria

Highmark uses nationally recognized clinical review criteria, medical policy and Medicare guidelines in determining whether a requested procedure, therapy, medication, or piece of equipment meets the requirements of medical necessity. This is done to ensure the delivery of consistent and medically appropriate health care for our members.

If a PCP or specialist requests a service that a clinician in Medical Management & Policy is unable to approve based on criteria/guidelines, the clinician will refer the request to a Highmark Physician Reviewer. A Highmark Physician Reviewer may contact the PCP or specialist to discuss the request or to obtain additional clinical information. A decision is made after all of the clinical information has been reviewed.

At any time, the PCP or specialist may request a copy of the criteria/guidelines used in making medical/surgical decisions by calling Highmark at 1-800-421-4744. To request a copy of the criteria/guidelines used in making behavioral health decisions, call 1-800-258-9808.

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Patient Notification of Approvals, Denials

All network providers are expected to notify their Highmark patients of both approval and denial of coverage decisions as soon as possible upon their office receiving notification of the decision from Highmark or a delegated entity of Highmark.

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Help Your Patients Manage Chronic Conditions

You know that many of your patients struggle with one or more health conditions that may slow them down, cause pain, and interfere with quality of life. Those conditions can take a toll on work, family and social life.

You also know the good news: that even serious health conditions can be managed and that the need for emergency care and unnecessary hospitalization can be reduced. Condition management programs are available to Highmark members who need help managing chronic health conditions, including:

asthma diabetes congestive heart failure coronary artery disease chronic obstructive pulmonary disease

depression hypertension high cholesterol high-risk pregnancy inflammatory bowel disease

metabolic syndrome migraine musculoskeletal pain osteoporosis upper GI

A Highmark Health Coach — a registered nurse or health care specialist who teams up with you, the doctor — can help your patients develop the skills they need to manage their conditions and improve their health and quality of life. Our condition management programs cover all aspects of dealing with a chronic condition, such as understanding a new diagnosis, taking the right medicine at the right time, managing symptoms and changing habits and behaviors that affect overall health. Our Health Coaches provide patients with materials and resources designed to be supportive of your plan of care. There is no cost to the member for these programs.

So, if you have a patient with one or more of the conditions noted above (or any other health concerns), you can refer the patient to Blues On Call by asking him or her to call 1-888-BLUE-428 (1-888-258-3428). Physicians can also refer patients directly by completing the Blues On Call^SM referral form and faxing it to the toll-free number on the form. The form is available online in our Provider Resource Center; click on Blues On Call, choose Practice Resources, and select the form name from the available links.

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Member Rights and Responsibilities

Our members have certain rights and responsibilities that are a vital part of membership with a managed care or PPO plan. These rights and responsibilities are included in the member handbooks and are reviewed annually in the member newsletter.

We also make them available online for our network providers to help you maintain awareness and support your relationship with your Highmark patients. (From the Resource Center, click on Administrative Reference Materials, then Highmark Blue Shield Office Manual. You'll find the Member Rights and Responsibilities in Chapter 3, Unit 2.) A paper copy of the Member Rights and Responsibilities is available upon request.

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Peer-to-Peer Conversations: Availability of Physicians, Behavioral Health Practitioners, and Pharmacist Reviewers

Highmark provides you with an opportunity to discuss Utilization Management (UM) denial decisions with a clinical peer reviewer following notification of a denial determination. Clinical peer reviewers are licensed and board-certified physicians, licensed behavioral health care practitioners, and licensed pharmacists, and they are available to discuss review determinations during normal business hours. Your call will be connected directly to the peer reviewer involved in the initial review determination, if he or she is available. If the original peer reviewer isn’t available when you call, another clinical peer will be made available to discuss the denial determination within one business day of your request. To request a peer-to-peer conversation, you may call the appropriate number listed in the chart below:

PRACTITIONER/ ORDERING PROVIDER	UM ISSUE	TELEPHONE NUMBER
Practitioners	Med/Surg UM decisions	1-866-634-6468
Behavioral health providers	Behavioral health	1-866-634-6468
Pharmacists	Pharmacy services	Telephone number identified on determination letter
Practitioners	Advanced radiology imaging	Telephone number identified on determination letter
Practitioners	Radiation Therapy	Telephone number identified on determination letter
Practitioners	Physical Medicine	Telephone number identified on determination letter