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Notifications for Providers

Several times annually, Highmark notifies providers of important policies and guidelines.
The following notifications are for your information and reference.

Preventive Health Guidelines Available Online

Highmark and participating network physicians annually review and update the Preventive Health 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 Education/Manuals, and then select Preventive Health Guidelines.

The Preventive Health Guidelines include:

  • Adult (under and over 65)
  • Pediatrics
  • Prenatal/perinatal

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

Appropriate Utilization Decision Making

Highmark makes utilization review decisions based only on the necessity and appropriateness of care and service and the existence of coverage. In addition, Highmark does not 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 review decision-makers to encourage denials of coverage.

Request for Criteria

Highmark uses resources such as 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 and appropriateness. 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 Utilization Management 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.

Patient Notification of Approvals, Denials

All network providers are expected to notify their patients who are Highmark members 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.

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
  • Heart failure
  • COPD
  • Depression
  • High-risk pregnancy
  • Metabolic syndrome
  • Musculoskeletal pain

 

A Highmark clinician — a member of Highmark's staff who is trained as a registered nurse or health care specialist who teams up with you, the doctor — can help your patients (our members) 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 clinicians provide members 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 who is a Highmark member with one or more of the conditions noted above (or any other health concerns), you can refer the patient to Blues On CallSM by asking him or her to call 1-888-BLUE-428 (1-888-258-3428).

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 patients who are Highmark members. (On the Provider Resource Center, click on Education/Manuals. You'll find the Member Rights and Responsibilities in Chapter 1, Unit 5, of the Highmark Provider Manual.) A paper copy of the Member Rights and Responsibilities is available upon request.

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

Highmark provides you with an opportunity to discuss utilization review 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.

*IMPORTANT NOTE: The peer-to-peer review process is no longer available for Medicare Advantage members. See Chapter 5, Units 3 and 5, of the Highmark Provider Manual for details.

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

 

Provider Accessibility Expectations

To stay healthy, our members must be able to see their physicians when needed. To support this goal, Highmark’s expectations for accessibility of primary care physicians (PCPs), medical specialists, obstetricians, and behavioral health providers are outlined below.

The standards set forth specific time frames in which network providers should respond to member needs based on symptoms.

Physicians are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

PCP and Medical Specialist Accessibility Expectations

Patient’s Need:

Performance Standard:

Emergency/life-threatening care

  • Sudden, life-threatening symptom(s) or condition requiring immediate medical treatment (e.g., chest pain, shortness of breath)

Immediate response

Urgent-care appointments

  • An urgently needed service is a medical condition that requires rapid clinical intervention as a result of an unforeseen illness, injury, or condition (e.g., high fever, persistent vomiting/diarrhea)

Office visit within 1 day (24 hours)

Regular and routine care appointments

  • Non-urgent but in need of attention appointment (e.g., headache, cold, cough, rash, joint/muscle pain)
  • Routine wellness appointments (e.g., asymptomatic/preventive care, well child/patient exams, physical exams)

Pennsylvania and West Virginia:
• Within 2-7 days (Non-urgent)
• Within 30 days (Routine wellness)

Delaware:
Office visit within 3 weeks of member request

After-hours care

  • Access to practitioners after the practice’s regular business hours

Acceptable process in place to respond
24 hours per day, 7 days a week to
member issues (answering service that
pages the practitioner or answering
machine message telling caller how to
reach the practitioner after hours)

In-office waiting times

  • Practitioners are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

Within 15 minutes

 

Maternity Care Accessibility Expectations (Obstetrics)

Patient’s Need:

Performance Standard:

Maternity Emergency

Immediate response

Maternity 1st Trimester

Within 3 weeks of first request

Maternity 2nd Trimester

Within 7 calendar days of first request

Maternity 3rd Trimester

Within 3 calendar days of first request

Maternity High Risk

Within 3 days of identification of high risk

 

Behavioral Health Provider Accessibility Expectations

Patient’s Need:

Performance Standard:

Care for a life-threatening emergency

  • Immediate intervention is required to prevent death or serious harm to patient or others

Immediate response

Care for a non-life-threatening emergency

  • Rapid intervention is required to prevent acute deterioration of the patient’s clinical state that compromises patient safety

Care within 6 hours

 

Urgent care

  • Timely evaluation is needed to prevent deterioration of patient condition

Office visit within 48 hours

Routine office visit

  • Patient’s condition is considered to be stable

Pennsylvania and West Virginia:
Office visit within 10 business days

Delaware:
Office visit within 7 calendar days

After-hours care

  • Access to providers after the practice’s regular business hours

Acceptable process in place to respond
24 hours per day, 7 days a week to
member issues (answering service that
pages the provider or answering
machine message telling caller how to
reach the provider after hours)

In-office waiting times

  • Providers are encouraged to see patients with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify patients of delays.

Within 15 minutes

 

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