Provider Data Accuracy Compliance

EDUCATIONAL PRESENTATION

WHAT TO EXPECT DURING AN AUDIT CALL

PROVIDER DATA MAINTENANCE GUIDE


The Centers for Medicare and Medicaid Services (CMS) requires of Highmark and its network providers that current, accurate provider data is published in Highmark's Provider Directory.  The Provider Directory is an important tool that helps our members contact practitioners, and the data itself is what drives timely and accurate claims processing. Additionally, please note that if you do not maintain accurate provider data, your status within Highmark’s networks may be impacted, resulting in the inability to service patients who have Highmark insurance.

Highmark is committed to ensuring the information in the Provider Directory meets our standards for quality and the standards set forth by CMS. CMS requires ongoing review of all physician information listed in the directory to confirm:

  • The provider name is correct.
  • The practice name is correct.
  • The provider’s specialties are correctly listed.
  • There are not providers listed at practice locations where they do not schedule appointments.
  • The provider is accepting new patients, or not accepting new patients, at the location.
  • The provider’s street address and phone number are correct.

There are two ways you can update your directory information with Highmark, the first is through Availity® under Provider Data Maintenance.

To access Provider Data Maintenance:

  1. Log into Availity
  2. Click on Payer Spaces and choose the appropriate Highmark plan(s)
  3. Scroll down and select Provider Data Maintenance under the Applications tab

 

You can also update your directory information by completing the appropriate forms on the Provider Resource Center.

To access the forms:

  1. Click Forms in the left-hand menu
  2. Select Provider Information Management Forms
  3. Fill out the appropriate form

*For Facility and Ancillary Providers, please use the Highmark Facility/Ancillary Change Form to submit any changes.

Last updated on 2/8/2024 2:39:05 PM

 

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