Staying Up to Date With the Highmark Provider Manual

Ensure you are regularly reviewing the Highmark Provider Manual for our most recent guidance on:

  • Participation Rules
  • Credentialing/Recredentialing Criteria and Procedures
  • Medical Record Criteria
  • Requirements for 24/7 Coverage

Some recent noteworthy changes include:

  • Chapter 2 Unit 3 – Other Government Programs:
    • Information on CHIP eligibility has been updated to reflect all eligibility forms and questions should be directed to the Department of Human Services instead of Highmark.
  • Chapter 3 Unit 2 – Professional Provider Credentialing:
    • Information on sanctions has been added throughout this unit.
    • The facility-based practitioner credentialing policy has been updated.
  • Chapter 4 Unit 4 – Ancillary Services, Chapter 5 Unit 1 – Care Management Overview, Chapter 5 Unit 2 - Authorizations, Chapter 5 Unit 3 – Medicare Advantage Procedures:
    • References to Tivity or WholeHealth Network have been replaced by the company’s new name, WholeHealth Living.
  • Chapter 6 Unit 2 – Electronic Claim Submission:
    • The NY address and fax number have been added to Electronic Claim Attachments.
    • The New York NAIC Codes/Plan Codes have been updated.

 

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