Clinical/Operational Updates

ADMINISTRATIVE UPDATES

QUARTERLY DIRECTORY DATA VALIDATION

  • Effective May 7, 2020

The Centers for Medicare & Medicaid Services (CMS) requires Highmark to have the most current information for our network providers and also requires ongoing review of all physician information listed in our online and printed provider directories. Atlas has been selected as a vendor on behalf of Highmark to conduct quarterly outreaches as part of the CMS directory requirement. Effective May 7, 2020, Highmark will resume a modified quarterly validation process and Atlas will begin making phone calls to provider offices for data verification. Read eBulletin IMPORTANT UPDATE: ATLAS OUTREACH CALLS RESUMING FOR THE QUARTERLY DIRECTORY DATA VALIDATION PROCESS for additional information.

  

EXPEDITED CREDENTIALING OF PROVIDERS DUE TO COVID-19

To ensure our members have timely access to care during the COVID-19 Public Health Emergency (PHE), Highmark is temporarily relaxing its credentialing requirements in line with federal guidelines. Read eBulletin EXPEDITED CREDENTIALING OF PROVIDERS DUE TO COVID-19 for additional information.

 

ALTERNATE HEDIS CHART SUBMISSION GUIDELINES

To further support containment of COVID-19, Highmark is encouraging all providers to fax any HEDIS® chart requests back to the designated return fax number identified on the original chart request. This change was communicated in eBulletin HEDIS CHART REVIEW AND ALTERNATE SUBMISSION GUIDELINES REGARDING THE CORONAVIRUS 2019 (COVID-19).

 

AUTHORIZATIONS

AUTHORIZATION EXTENSIONS

  • Expired March 31, 2021

Highmark has extended the timeframe for new prior authorization requests for ancillary/DME and inpatient planned surgeries through March 31, 2021. Read ebulletin EXTENDED: OPEN AUTHORIZATIONS for detailed information.

 

PLACE OF SERVICE CHANGES FOR AUTHORIZED SERVICES

To address the evolving nature of the COVID-19 health crisis, providers may need to adjust the place of service for authorized services more than usual. Highmark is committed to assisting you in this important effort to ensure that our members have continued access to quality health care despite the challenging circumstances. Please review eBulletin PLACE OF SERVICE CHANGES FOR AUTHORIZED SERVICES to ensure a seamless transition for your patients.

 

PEER-TO-PEER REVIEW TIME FRAME

In order to continue to support you and our members through the COVID-19 situation, Highmark is increasing our peer-to-peer review time frame from 60 days to 180 days for any denials. We want to ensure all our members receive a full and fair review despite the constraints we are all facing. All other denial guidelines remain the same at this time for Commercial members.

 

CLAIMS, PAYMENT AND REIMBURSEMENT

MEDICARE SEQUESTRATION

  • Expires December 31, 2021

Highmark has aligned with Congressional action to extend temporary payment increases related to Medicare sequestration through December 31, 2021. Read ebulletin EXTENDED THROUGH DECEMBER 2021: MEDICARE SEQUESTRATION TEMPORARY PAYMENT INCREASE for detailed information.

 

CHANGES TO REIMBURSEMENT POLICY 041 (SERVICES THAT ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT)

  • Expired June 13, 2020

In alignment with the U.S. Department of Health and Human Services’ Office of Civil Rights (OCR) and The Centers for Medicaid and Medicare Services (CMS)’s guidelines for telemedicine during the COVID-19 national public health emergency, the following procedure codes are now eligible to be performed via telemedicine from March 13, 2020 through June 13, 2020. Read eBulletin CHANGES TO REIMBURSEMENT POLICY 041 for detailed information.

  

TIMELY FILING POLICY

  • Expired June 30, 2020

Due to the COVID-19 public health emergency, Highmark is modifying our timely filing policy temporarily for claim submissions from participating providers. All in-network providers will have 365 days to submit claims with dates of service beginning February 1, 2020, through June 30, 2020.

 

POST-PAY CLAIM AUDITS

Highmark’s Financial Investigation and Provider Review (FIPR) team is mindful of the current COVID-19 pandemic and strain on the administrative resources available to respond to post-pay claim audits. Effective immediately, the timeframe in which to respond to medical record requests or to request an appeal for a claim audit finding will be extended from 30 days to 90 days. This timeframe extension will apply to all inflight professional and facility post-pay claim audits starting on or before May 31, 2020 managed either by FIPR or one of FIPR’s external audit partners (e.g. CGI, Equian or Trend Health Partners).

 

MEDICAL POLICY

IMPORTANT: MEDICAL POLICY CHANGES TO ADDRESS EASY ACCESS TO NECESSARY SUPPLIES DURING COVID-19 OUTBREAK

  • Effective March 6, 2020

The Centers for Medicare & Medicaid Services (CMS) has issued temporary waivers for paperwork requirements for respiratory-related devices and other necessary equipment in order to improve patient access to the care they need. Highmark is responding to the rapidly evolving situation by adopting the CMS guidance for both our Commercial and Medicare Advantage lines of business, effective March 6, 2020. Read eBulletin POLICY CHANGES TO ADDRESS EASY ACCESS TO NECESSARY SUPPLIES DURING COVID-19 OUTBREAK for more details.

 

PHARMACY

PRESCRIPTION MEDICATION REFILLS

We are increasing access to prescription medications by waiving early medication refill limits on 30-day prescriptions and encouraging members to use 90-day mail order benefits when available.

Last updated on 9/15/2021

 

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