Urgent Reminder: Ensure Accurate Provider Directory Information

The Centers for Medicare & Medicaid Services (CMS) requires Highmark to conduct a quarterly outreach to validate provider information.* We use this information to populate our Provider Directory and to ensure correct claims processing.

Our members use Highmark’s Provider Directory to make the best, informed decisions when selecting a provider. It is, therefore, to your advantage to make sure your directory information is correct and current.

Highmark is committed to ensuring the information in the Provider Directory meets our standards for quality. Providers who do not validate their data will be immediately removed from the directory. Your status within Highmark’s networks may be impacted.

CMS requires a quarterly review of all physician information listed in the directory to confirm:

• The provider name is correct. For example, if a provider marries, we must ensure the provider’s name in the directory matches the name on his/her medical license.
• The practice name is correct. For example, is there a difference between the practice name that is being used when phones are answered, versus the practice name listed in the directory?
• The provider’s specialties are correctly listed. Is there more than one specialty listed in the directory? Are both specialties being practiced?
• There aren't providers listed at practice locations where they don’t actually practice. Providers listed must be affiliated with the group. Providers who cover on an occasional basis are not required to be listed. Providers who do not see patients on a regular basis at a location should not be listed at that location. 
• The provider is accepting new patients — or not accepting new patients — at the location.
• The provider’s street address and phone number are correct.

It’s vital that all providers review and update their information in NaviNet^®. Information should be updated as soon as a change occurs. All data should be reviewed at a minimum of once a quarter to ensure it’s accurate. Detailed instructions are available in the Provider File Management NaviNet Guide , which is available on the Provider Resource Center under Education/Manuals.

We are currently making outreach calls to providers to verify the accuracy of provider data. If you receive a call, please provide the agent with the requested information.

*IMPORTANT NOTE: Delaware law also requires accurate information and timely updates to health plan provider directories.