Notifications for Providers

Several times a year, Highmark notifies providers of important policies and guidelines. The following notification is for your information and reference.

2020 HEDIS® Audit Results

The Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used set of performance measures in the managed care industry. Developed by the National Committee for Quality Assurance (NCQA®), HEDIS is part of a larger system that complements the NCQA accreditation program and establishes accountability in health care.

In areas of most concern to your patients, HEDIS helps compare how managed care plans perform.

HEDIS data is collected annually for members of Highmark’s various products. The HEDIS measures span many areas of care delivery and service:

  • Effectiveness of care
  • Access/availability of care
  • Experience of care
  • Utilization and risk-adjusted utilization
  • Health plan descriptive information

Using this subset of HEDIS measures, the performance of services that Highmark members received in measurement year (MY) 2019 for the HEDIS reporting year (RY) 2020 is compared to the 2020 national averages. For additional comparison, MY 2019 results are included.

You may review these results on the Provider Resource Center by:

  • Going to Education/Manuals
  • Clicking HEDIS
  • Selecting HEDIS Results

Important Note: The source of the National Average data contained in this publication is from Quality Compass® 2020 and is used with the permission of NCQA®. Quality Compass 2020 includes certain CAHPS® data. Any data display, analysis, interpretation, or conclusion based on this data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion.

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 the Provider Resource Center 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:

Director, Health Plan Quality
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 primary care physician (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 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 for Medical/Surgical-related criteria/guidelines
  • 1-800-258-9808 for Behavioral Health-related criteria/guidelines
  • 1-800-600-2227 for Pharmacy-related criteria/guidelines

This information is also available online:

  • Highmark’s medical and pharmacy policies are available via the Provider Resource Center (PRC)
  • The Federal Employee Program (FEP) Medical Policy Manual is available via the FEP’s website at
  • The FEP Pharmacy criteria/guidelines are available via the following link: FEP Pharmacy Criteria/Guidelines

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.

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.

Quality Program Information Available Online

Highmark’s Quality Program has been designed to improve the quality, safety, and equity of the clinical care and services providers render to our members. To do this, we continually review aspects of the program that affect the quality of the member care experience and satisfaction and look for ways to improve them.

Highmark works closely with the physician community in our efforts to address both the quality of the clinical care and service our members receive, as well as plan management to address the services provided by Highmark (i.e., authorizations, claims handling, appeals, etc.). We also use member satisfaction surveys and other tools to get feedback on how we’re doing. These results are used to guide our future quality improvement activities and programs supporting such focuses as the clinical care and service received by our members, the provider network, member safety and health equity.

For more information about the Quality Program, including information about program goals and a report on progress toward meeting those goals, please visit our online Provider Resource Center via NaviNet® or through Once on the Provider Resource Center, from the black navigation bar at the top, select Highmark Provider Manual. See “Chapter 5: Care & Quality Management, Unit 6: Quality Management.”