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 occurred in the following chapters and units:
  • Chapter 1, Unit 2: Online Resources & Contact Information
  • Chapter 2, Unit 2: Medicare Advantage Products & Programs
  • Chapter 3, Unit 2: Professional Provider Credentialing
  • Chapter 4, Unit 2: Behavioral Health Providers
  • Chapter 5, Unit 4: Behavioral Health
  • Chapter 5, Unit 5: Denials, Adverse Benefit Determinations, Grievances, and Appeals
  • Chapter 6, Unit 3: Facility (UB-04/8371) Billing
  • Chapter 6, Unit 4: Professional (1500/837P) Reporting Tips

Relinquishment of Washington County, Ohio

Highmark Blue Cross Blue Shield in West Virginia relinquished the Washington County, Ohio, service area. The change — which was requested by Highmark — was approved by the Blue Cross Blue Shield Association (BCBSA) in November 2023.

For this reason, references to Washington County, Ohio, were removed from the following areas of the manual:

  • 1.1 About Highmark
  • 1.2 Highmark Websites (PUBLIC WEBSITES section)
  • 2.1 Introduction (HIGHMARK’S CORPORATE ENTITIES section)
  • 3.1 Directing Care to Network Providers (LOCATING NETWORK PROVIDERS section)

To see the full list of recent changes, visit the Highmark Provider Manual Changes page.


 

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