A newsletter for Highmark Blue Shield of Northeastern New York (Highmark BSNENY) network providers
Issue 2, February 2023
Starting June 1, 2023, Highmark will begin auditing all outpatient Emergency Department facility claims to ensure the correct procedure codes are being billed. This may result in a different reimbursement than expected, with Highmark updating the claim to correct the procedure code.
These audits are designed to determine the appropriate and fair level of facility reimbursement for emergency department services based on the Centers for Medicare and Medicaid Services (CMS) criteria to determine the appropriate procedure code. Highmark will review the diagnoses submitted as well as the services performed to determine the appropriate level of care for the visit on a scale of one (1) through five (5).
On February 27, 2023, Highmark will update Reimbursement Policy RP-037: Emergency Evaluation and Management Coding Guidelines 
with a full description of these changes.
If the audit determines your claim warrants the level of care at which the claim was billed, the claim will not be changed. If we determine the claim warrants a different level of care, Highmark will add a new line with the correct procedure code and reimburse you at the updated rate.
If Highmark lowers your level of care, you will be able to see the new procedure code on your Explanation of Benefits (EOB). The code you originally submitted on the claim and the code Highmark adds to the claim will be stored in our systems for CMS audits. However, your EOB will only show the procedure code that Highmark inserts onto the claim.
If you disagree with the level of care that Highmark determined through the audit, you can file an appeal with Highmark. To appeal, you will need to submit all related medical records to Highmark’s Medical Review team as outlined in Chapter 5 Unit 5 of the Highmark Provider Manual.
To locate the Highmark Provider Manual , hover over Manuals in the quick access bar at the top of the Provider Resource Center and select Highmark Provider Manual.
