What does the affiliation mean?
- In March 2021, we officially became an affiliate of Highmark Inc.
- With this affiliation, we’ll remain the local, not-for-profit Blue plan you’ve always worked with; but we’ll have Highmark’s technology and solutions to better serve you and your patients
- We’ve integrated our claims processing systems and some workflows and policies have changed as your patients have moved to Highmark’s system
- As of January 1, 2023 all patients have been moved onto Highmark’s system
Are Medicaid and Child Health Plus (CHP) patients going to be moved to Highmark systems?
- Not at this time - they will continue to be managed by Amerigroup under existing procedures and policies
Will I need to sign up for NaviNet®?
- Yes, you need access to NaviNet
- NaviNet is an easy online solution linking providers with Highmark and other health plans. NaviNet integrates all insurer-provider transactions into one system
- Please register for NaviNet if you don’t already have access
- Some administrative transactions (such as prior authorization requests) will be available electronically through NaviNet, and we believe this will ultimately help to reduce some administrative burden for your practice
- If you are already registered with NaviNet to interact with another payer, the Highmark BCBSWNY health plan will be added as options for you under the My Health Plans menu. If you don’t see them as options in the My Health Plans menu, please follow these steps to request access
How do I sign up for NaviNet?
- You’ll need to determine a member of your staff to be your NaviNet Security Officer
- The NaviNet Security Officer serves as the primary contact between your office and NaviNet and is responsible for:
- Registering your office
- Adding and deactivating office users
- Setting up access permissions
- Please note: When registering with NaviNet, you’ll need to use the service address listed on file with Highmark BCBSWNY NOT a PO box, billing (unless it’s the same as the service address) or personal address
- Click here to register your office for NaviNet; A Federal Tax ID number is required for registration
- If you think you are already registered with NaviNet for other payers, click here to check your NaviNet registration status
Where can I find guidance on using NaviNet?
How do I enroll for electronic fund transfers (EFT)?
- After registering with NaviNet, providers must also enroll in electronic funds transfer (EFT) and paperless explanation of benefits (EOB) statements or remittances
- You can enroll in EFT through the EFT Attestation and Registration transaction in NaviNet
- Your office’s NaviNet Security Officer must enable EFT Attestation and Registration transaction for the designated “EFT Responsible Party”
- Your EFT Responsible Party will be able to electronically attest, register, and/or maintain banking information on behalf of your office
- Once you are enrolled and start receiving EFT payments, your office will no longer receive paper EOB statements or remittances; you can view all your electronic EOBs or remittances via NaviNet
- Click here for additional information about EFT Attestation and Registration
I updated my banking information in PaySpan, do I need to do anything in NaviNet?
- Once you register for NaviNet, you’ll be able to view and make changes to your banking information
- Your designated NaviNet Security Officer will be able to electronically attest, register, and/or maintain banking information on behalf of your office
How will I check eligibility for my patients?
- For all patients, eligibility and benefits can be checked via NaviNet
- You can also use HEALTHeNET to check eligibility
How do I check eligibility if my patients don’t have their new Highmark ID card?
- You may verify eligibility and benefits on NaviNet
- You may also use HEALTHeNET as long as you have at least two of the following for your patient:
- ID number
- Date of birth
- First and last name
- For questions or issues verifying eligibility on NaviNet or HEALTHeNET, you can still call Provider Service at 1-800-950-0051
- Please note: FEP Provider Service can be reached at 1-800-234-6008
If I am currently enrolled in EFT through PaySpan, will my payments still come electronically for patients on Highmark’s systems?
- Yes, if you previously enrolled in EFT through PaySpan, you will continue to receive payments electronically
- We encourage you to verify your banking information in NaviNet
- You will be able to view EOBs in NaviNet Online
- BestPractice vouchers will continue to come from PaySpan
Where should I go to check fee schedules for my patients?
- Fee schedules will be on Highmark’s provider portal/NaviNet
How will payments to dual-specialty providers be handled?
- Claims submitted by dual-specialty providers will process based on your specialty type and whether you submit services rendered as a specialist or primary care physician; please continue to submit claims using your appropriate taxonomy code
- There may be instances where a claim will process and apply a PCP cost share when a specialty cost share should have been applied, and vice-versa, for your patients as they move onto Highmark’s system (For example: a PCP copay vs. a specialist copay)
- If you identify a claim you feel has processed incorrectly, please contact Provider Service
How do I submit claims?
- Claims for all patients will continue to be submitted electronically through Administrative Services of Kansas, Inc. (ASK)
- Paper claims can be mailed to: PO Box 4208 Buffalo, NY 14240-0080
My patient’s last name is missing a letter on their Highmark ID card. How should I submit claims for this patient?
- Claims should be submitted with the patient’s complete first and last name, even if their last name is missing a letter
Can I bill using either a UB04 or CMS1500 form?
- Highmark is closely aligned with CMS, so you should use the UB04 or CMS 1500 form depending on how your practice is credentialed with us; for example:
- If you are credentialed as a facility such as a hospital, substance abuse treatment center or skilled nursing facility, you should generally use a UB04
- If you are an ancillary provider, such as urgent care, ambulance, durable medical equipment (DME) or home infusion, you should use the CMS 1500 form
- If you are a specialist in a specialty group or part of a primary care practice, you should use CMS 1500
- Review Chapter 3 Unit 4 of the Highmark Provider Manual for specific guidance on which forms should be used by which providers
- Highmark will only accept and process original red 1500/Version 02/12 and UB-04 claim forms for Highmark BCBSWNY. Photocopies or outdated versions of the forms will be returned and will need to be resubmitted
What is Highmark’s claims processing system?
- Highmark’s system and policies adhere closely to established standards from the American Medical Association, CMS and other clinical editing standard bearers
- Highmark utilizes the Optimum Systems for Claims Adjudication and Reporting (OSCAR) claims processing system
- For questions about clinical editing, please review Highmark’s Reimbursement Policy or contact Provider Service
- As always, questionable, incomplete or unclear claims may require that providers submit an itemized bill or medical record support before payment can be processed
How have your reimbursement policies changed?
- We have adopted Highmark’s reimbursement policies
- Please review Highmark’s Reimbursement Policy or contact Provider Service for guidance on coding, use of modifiers and reimbursement
Will preventive services draw a $0 cost share/be reimbursed the same way?
- We’ve aligned our preventive lab services to include only the U.S. Preventive Services Task Force (USPSTF) recommendations
- There is a change for claim submission as $0 cost share for your patients will only apply to preventive labs submitted with a routine diagnosis code. Therefore, labs ordered for an existing medical disease billed with a medical diagnosis code will apply cost share for your patient:
- If a medical diagnosis of diabetes is on the claim with HBA1c procedure code, a cost share will be charged to the patient
- If a routine diagnosis (screening for diabetes Z131) is on the claim with HBA1c procedure code, a $0 cost share will be charged to the patient
- Examples of other labs that pay as preventive ($0 cost share) when paired with routine diagnosis codes include:
- HIV screening Z114, other viral Z1159 or bacterial disease Z112 screening diagnosis and Z113 for STIs Gonorrhea, Syphilis, Chlamydia and HIV labs
- Viral screening Z1159 for Hepatitis B and C screening labs 86704, 86705, 86706, 87340, 87341, 86803, 86804, 87520, 87521, 87522, G0472
- Nutritional disorder screening diagnosis Z1321 for vitamin D 82306 or vitamin B12 82607 labs
- Malignancy of prostate Z125 for PSA labs G0102 and G0103
- Cervical Cancer Screening diagnosis Z124 for Pap lab G0145
- HPV screening diagnosis Z1151 for HPV lab
- Lipid disorder screening diagnosis Z13220 for lipid panel 80061
- Screening for depression Z1331 with depression screening G0444
- Bacterial disease screening Z113 with urinalysis 81001
- Metabolic disorder screening Z13228 with thyroid test 84443
- Metabolic disorder screening Z13228 with metabolic panel 80050 and 80053
- Metabolic disorder screening Z13228 with CBC 85025
- Other general preventive reminders include:
- Diagnostic services billed with a preventive diagnosis will be denied and the patient will be liable for the cost
- Please continue to utilize CPT and HCPCS coding resources to select the most appropriate screening diagnosis code for your patient and code all diagnosis codes to the highest specificity when possible
- Pap smear: use code G0145 (Screening Cytopathology, Cervical or Vaginal) instead of 88175 (Cytopathology, Cervical or Vaginal) with diagnosis code screening for malignant neoplasm of cervix Z124
- Use depression screening procedure code G0444 with screening diagnosis for depression Z1330
- Z1332 maternal depression screening with 96161 caregiver depression screening done by pediatrician during infant well child visit
- Low dose lung cancer screening needs Z122 or Z87891 diagnosis code with procedure code 71271
- Preventive benefits will follow calendar year administration
How do I make a claim inquiry/request?
- To see how a claim was processed and why (known as “provider inquiry” in HEALTHeNET), you can submit a Claim Investigation Inquiry in NaviNet
How can I check claims status?
- You can review detailed claims information, check claim status, and launch a claims investigation through NaviNet’s Claim Status Inquiry tool
- Claims status can also continue to be checked on HEALTHeNET
How should I submit provider information on a claim?
- Because Highmark contracts at the group level, the claims system requires that the billing provider be submitted as the group and not the individual provider
- While we currently accept either, you may need to make this change to avoid delays and/or denials
- The only instance where we will accept an individual provider’s NPI as the billing provider is if the provider is a sole practitioner who does not have a Group NPI
- If the Provider who renders the service is part of a provider group or facility and that group or facility is receiving the payment, then the “billing provider” on the claim MUST contain the group or facility information including Name, NPI, Address and Tax ID
- The provider who rendered the service must be billed as the “rendering provider” including Name, NPI and any applicable taxonomy code
- Billable groups will continue to list only the group as the billing provider (with no rendering provider)
- Example: Dr Jane Doe is a member of Provider Group ABC
- 837 Electronic Billing Guidelines
- Provider Group ABC submitted in Billing Provider Loop 2010AA
- Jane Doe submitted in Rendering Provider Loop 2310B
- CMS1500 Paper Billing Guidelines
- Provider Group ABC submitted in Billing Provider Box 33
- Jane Doe submitted in Rendering Provider Box 24J
Are there any changes to claim edits when submitting electronically to ASK (Administrative Services of Kansas)?
- To help process your claims quickly and avoid denials and rejections, we are recommending providers begin to adopt industry standards today that have not always been enforced in our system but are likely to be required in the future
- As we adopt Highmark’s claims edits, please ensure your claims are HIPAA Standard-compliant:
- 837I (Institutional Claims)
- Billing and service facility U.S. addresses must contain a valid 9-digit zip code; we will no longer accept the last 4 digits as “0000”
- Admitting physicians must be included on all claims other than non-scheduled transportation claims
- Operating physician must be submitted when a surgical procedure code is listed on the claim
- When submitting an interim bill, the discharge status must be “30” indicating the member is still a patient
- “Present on admission” indicators are required on inpatient claims unless exempt
- A procedure code description is required when the procedure code is “Unlisted”
- 837P (Professional Claims)
- Billing and service facility U.S. addresses must contain a valid 9-digit zip code; we will no longer accept the last 4 digits as “0000”
- Procedure code description is required when the procedure code is “Unlisted”
- Admission date is required for inpatient claims
- Anesthesia-related procedure codes submitted must be valid surgery codes
- Service line dates of service must be greater than or equal to the submitted hospital inpatient admission date
Why do I have to have to include member ID on claim status?
- Highmark’s process requires you to include a member ID when checking claim status
- For more information, review the HEALTHeNET tipsheet here
Are there billing changes for behavioral health providers?
- To avoid claim denials, behavioral health providers must now include the correct taxonomy and performing provider information (when applicable) on 837P electronic claims for Legacy and Highmark system patients
- Individual Credentialed Providers
- Individual providers who are credentialed with Highmark BCBSWNY must include the NPI number and taxonomy of the billing provider in the billing provider loop
- You must use the taxonomy code that corresponds with the specialty type of the billing provider group:
- Same-specialty groups (Example: all Clinical Social Workers) must use taxonomy code 1041C0700X
- Multispecialty groups must use taxonomy code 193200000X
- Individual credentialed providers must also include the NPI number AND taxonomy code of the performing provider in the performing/rendering provider loop
- The following provider types should bill in this manner:
- Certified Social Worker
- Independent Psychiatric Nurse Practitioners
- Licensed Mental Health Counselors (LMHC) credentialed for Commercial (non-Medicare Advantage) plans ONLY
- Psychiatrists (MD or DO)
- Providers Covered Under a Billable Group
- Providers who are covered under a billable group (not individually credentialed with Highmark BCBSWNY and bill using a CMS 1500 claim form must include the NPI number of the billing provider group along with taxonomy code 101YM0800X
- Please note: The rendering provider loop must remain BLANK. You do not need to include an NPI number or taxonomy code in this loop
How will I know where to send dental surgery claims?
- Dental and Oral surgery claims should be sent directly to United Concordia Dental. Any codes that are not covered under the member’s Dental plan will automatically cross over to Highmark’s system for potential medical coverage. Any claims submitted to UCD for procedures not covered under your patients’ dental plan will be automatically routed to Highmark’s system for medical coverage review.
- Click here to view the Dental Resource Page
How long do I have to request a claim adjustment or submit a correction?
- Effective January 1, 2022, you will have 365 days from the date of service or date of discharge (for inpatient claims) to request an adjustment on a claim or to submit any corrections for your legacy and Highmark system patients.
- For example, if a claim has a date of service August 1, 2022, you will have until July 31, 2023 to submit an adjustment request on that claim.
What is the process for prior authorization requests?
- You will now be able to use the NaviNet electronic portal for requesting any prior authorization requests
- Prior authorization requests for high-end imaging, cardiac imaging and cardiac implantable devices will need to be submitted to NaviNet , which will route these to eviCore; Please review eviCore’s Highmark Cardiology and Radiology Code List or go to Highmark’s Advanced Imaging and Cardiology Services Program webpage to learn more
- Click here to view the webinar about eviCore’s Radiology/Cardiology Advanced Imaging prior authorization program for more detailed information
Note: NaviNet prior authorization process exceptions:
- Prior authorizations for radiation therapy for all ASO/self-funded patients will continue to be submitted by completing this prior authorization form located on the PRC under Forms > Authorization Forms and faxing to the number on the form
Where can prior authorization requirements be found?
Medical Injectable Drugs
- Please check which medications will require prior authorization by clicking here
- Please note that the following Highmark policies listed on their Provider Resource Center pages DO NOT APPLY TO NEW YORK CLAIMS:
Click “Requiring Prior authorization” on the Quicklinks bar at the top of the PRC page to check if a procedure or medication code requires prior authorization (Exception: Home Healthcare codes, which do NOT require prior authorization).
Are there phone and fax options for prior authorization requests in addition to electronic submission options?
- Yes, authorizations can be submitted by fax for all patients. Fax forms are available on the Provider Resource Center under the “Forms” tab on the left.
- Fax and phone numbers for Highmark system patients are:
- Medical: 1-844-946-6263
- Behavioral Health: 1-844-946-6264
- Medical outpatient (including provider-administered injectable medications): 1-833-619-5745
- Medical inpatient: 1-833-581-1868
- Behavioral Health outpatient: 1-833-581-1867
- Behavioral Health inpatient: 1-833-581-1866
Where can I find medical policies?
- You should review the Highmark medical policies on the PRC and clicking on the Medical Policy Search bar at the top of the page for your Commercial patients
Will patients need to get prior authorization for Home Healthcare?
How has pharmacy coverage changed?
- Express Scripts remains as our pharmacy benefits manager for Commercial and Medicare Advantage patients
- We always recommend checking pharmacy benefits for your patients before making prescribing decisions
- Go to the PRC and click on the Formulary Information button to check formulary coverage for your patients moved to Highmark plans; the following formularies will be available to your patients:
- Commercial Open/Incentive Comprehensive Formulary
- Commercial Closed Comprehensive Formulary
- Healthcare Reform (HCR) Comprehensive Formulary
- National Select Formulary
- The following programs DO NOT apply to New York claims:
- The Hemophilia and Bleeding Disorder Drug Program
- The Free Market Health Specialty Pharmacy Model
- The Copay Armor Drug List
Please note: FEP members will continue to be covered through CVS Caremark for retail pharmacy and mail order
How do I request medication prior authorizations and non-formulary requests?
- In-office medical injectable prior authorization can be submitted via NaviNet or by faxing requests to 1-833-619-5745
- Pharmacy medication prior authorization requests (patient self-administered) and non-formulary requests can be submitted electronically through Cover My Meds, or by faxing 1-866-240-8123
- Please visit CoverMyMeds.com to register for this prior authorization request option
- You can also call them at 1-866-452-5017 to get help with registration or using Cover My Meds for prior authorization
- To check which medical drug or NOC codes require prior authorization, please visit the PRC and click Requiring Prior authorization on the ribbon at the top of the page or check the Highmark Pharmacy Policy search to see which pharmacy benefit drugs have a policy attached (such as quantity limit or prior authorization)
Will Accredo continue as the specialty pharmacy provider for patients?
- Yes, Accredo will be the preferred specialty pharmacy for at-home/patient administered benefits
- Please check our policies which can be found at the Highmark Pharmacy Policy search before prescribing
- Policies that are applicable to New York patients can be identified in two ways:
- Within each policy document, the “Regions” section on the top left area of the policy will indicate which region(s) it applies to, and will have “All” or “New York” selected in instances where it applies to New York patients AND
- “New York” will also be included in the policy title for policies that apply only to New York members; there are six such policies that are exclusive to New York (not applicable to Highmark’s other regions)
How do I file claims/billing for medical (in-office) drugs?
- There has been no change to how you will file medical drug claims electronically
- For all medical drug claims, a National Drug Code (NDC) and Healthcare Common Procedure Coding System (HCPCS) code must be included on any medical drug code claim
- As always, if the codes or the combination are incorrect/invalid, the claim will be rejected, and you will need to resubmit the claim with the correct codes
- On the PRC, please click on the Pharmacy Program/Formularies button to review the “List of Procedure Codes Requiring NDC Information”
Can I continue to call my practice account liaison or network account representative for support?
- Yes, the local provider support team will continue to be available to you for assistance
- These individuals will be well-versed in any new processes or changes, so please contact them with any questions that arise
Can I still call Provider Service?
- Yes, our local Provider Service will continue to be available to you at 1-800-950-0051
- FEP Provider Service can be reached at 1-800-234-6008
Will providers still be able to get patient/population health data from Risk Manager?
How do I refer patients into Care and Disease Management?
- Patients can be referred into Care Management programs electronically through NaviNet
Where do I go to file an appeal?
- Please refer to the denial letter for accurate contact information regarding appeal and peer-to-peer requests
How will I be notified of a case determination?
- We will still call you with the determination and provide written notification
How do I contact the Behavioral Health Utilization Management team?
- You can use NaviNet
- Phone: 1-844-946-6264
- BH outpatient: 1-833-581-1867
- BH inpatient: 1-833-581-1866
Will there be changes to acute care facility inpatient level-of-care reviews?
- Facilities will need to submit admissions notifications through the NaviNet portal. Facilities can also use phone or fax:
- Phone: 1-844-946-6263
- Fax: (Medical inpatient) 1-833-581-1868
Will there be changes for Post-Acute Care Facilities?
- Admission notifications will be submitted through the NaviNet portal for patients on Highmark systems
- Authorization letters will be sent to facilities throughout a patient’s stay
- Post-Acute Care Facilities can also use phone or fax:
Fax: (Medical inpatient) 1-833-581-1868
Will I get a new contract from you?
- Yes, we will adopt Highmark’s practice of contracting at the provider group level
- This means that all individual network providers will need to be recontracted under a new group contract
- While this may be an inconvenience for providers in the short term, we believe it will be simpler going forward
- The group contracts may be sent to your practice through email, fax or regular mail
- Details of how to execute and return the contract will be included with the contract
The new contracts will not change your current reimbursement, incentives or value-based payments
Will we need to recredential?
- No, not until you are normally due to recredential with us (every three years)
- We will mail you a letter notifying you that it is time for recredentialing
- Recredentialing will still require that individual providers register with Council for Affordable Quality Healthcare (CAQH) and keep your profile up to date
- You will then need to log into CAQH Proview to review and re-attest to your CAQH application online
How will new providers in our practice get credentialed?
- For now, please continue to follow the existing process for credentialing providers
How will credentialing and recredentialing change for facilities?
- Credentialing for facility, organizational, and ancillary providers will still occur upon initial application with recredentialing required every 3 years after initial approval
- We will mail you a letter when you are due for recredentialing. This letter will include instructions on how to complete the recredentialing process online via the Highmark PRC
- Guidance on credentialing and recredentialing for facilities, organizations and ancillary providers can be found on the Highmark PRC Credentialing Page.
What is the new enumeration process for Advanced Practice Providers (APPs)?
- As of January 1, 2022, APPs, including Physician Assistants, Nurse Practitioners (with the exception of Independent Nurse Practitioners), Certified Registered Nurse Anesthetists, and Registered Nurse First Assistants will no longer have to be fully credentialed with us
- These provider types will only need to fill out a simple form online and will no longer have to complete a CAQH profile or submit a supervising physician form and Nurse Practitioner Agreement
- For more information on the new enumeration process, please review the Highmark Provider Manual, Chapter 3, Provider Network Participation
Will Quest continue as preferred lab provider?
Will Landmark continue to support your Care at Home program?
Which vendors will conduct provider billing reviews?
- You may be contacted by our third-party partners including CGI, Cotiviti, Trend, Equian and Change Healthcare regarding billing reviews