A newsletter for Highmark Blue Shield providers in northeastern New York
Issue 5, May 2024
Highmark Blue Cross Blue Shield requires that all credentialed network providers, per their contractual obligations, maintain accurate directory information and adhere to accessibility standards as detailed in the Highmark Provider Manual
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We are committed to ensuring that the information in the Highmark Provider Directory meets Centers for Medicare & Medicaid Services (CMS) regulations, New York State Department of Health (NYS DOH) regulations, and National Committee for Quality Assurance (NCQA) standards, as well as our own standards of quality.
In addition, members use the Highmark Provider Directory to make informed decisions when selecting a provider; therefore, it is also crucial to your organization to ensure your information is always accurate and up-to-date.
CMS requires Highmark Blue Cross Blue Shield to reach out to you every quarter and ask you to validate your provider directory information. See the article in this month’s Provider News on “How to Attest” your directory information.
To stay healthy, members must be able to see their physicians when needed. In support of this goal, Highmark Blue Cross Blue Shield has implemented accessibility standards that set forth specific time frames in which network providers should respond to member needs based on symptoms.
For example, when a member requires emergency care, the performance standard is an immediate response from the provider. For urgent care appointments, the standard of care is an office visit within 24 hours.
IMPORTANT: For members to schedule an appointment, the provider’s phone number needs to be correctly listed in the Provider Directory. In addition, the phone must be answered in a timely manner.
Pre-appointment scheduling conditions must not be imposed on members requesting an appointment, such as completing forms or access to previous medical records, prior to the provider scheduling the appointment.
The scheduling of the appointment must always be completed at the time the member calls the practice for an appointment. Appointments must be scheduled in compliance with the PCP and Medical Specialist/Behavioral Health Accessibility Expectations referenced below — not contingent on the member’s ability or inability to complete paperwork.
To review the full list of accessibility standards for professional providers, visit the following sections in the Highmark Provider Manual:
Facility services need to be available to Highmark members on a 24/7 basis when medically appropriate and in accordance with industry standards. Physician services are provided by either hospital-based physicians or physicians employed by a facility. If physician services are provided to Highmark members on behalf of a facility, the facility must verify that physician has the appropriate training, education, and licensure to provide such services.
To review the full list of accessibility standards for facilities and facility providers, visit the following section in the Highmark Provider Manual:
