A newsletter for Highmark Blue Shield providers in northeastern New York
Issue 5, May 2024
Highmark Blue Shield is beginning the process of moving professional providers in its New York markets onto Highmark Professional Agreements — which are group contracts that match the structure that is in place in the other Highmark service regions.
For offices with newly contracted individual practitioners, Highmark Professional Agreements(s) were sent out beginning in December 2023. For practices without newly contracted individual practitioners, offices will start seeing new contracts in their email inboxes in the second quarter of this year. For more information, click here.
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The 28th edition of MCG’s Care Guidelines will be available on Aug. 1, 2024.
After that date, you will be able to submit authorization requests using the 28th edition for any new requests. Any authorization requests with a start of care date prior to Aug. 1, 2024, will be reviewed using the 27th edition.
Please continue to use the Predictal Auth Automation Hub application in Availity® to submit authorization requests with clinical information included.
Medical Policy (MP) S-249 Amniotic Membrane and Amniotic Fluid Typing was recently published with a line of experimental and investigational procedure codes omitted. This error has been corrected and the policy was updated on May 17, 2024.
To view MP S-249 policy, go to the Provider Resource Center. On the top task bar, click the drop-down arrow for MEDICAL POLICY SEARCH, select MEDICAL POLICIES, and then type “S-249” into the search bar.
The Centers for Medicare and Medicaid Services (CMS) is requiring that insurers, including Highmark, collect additional documentation from facilities for Quality Improvement Organization (QIO) program audits, effective January 1, 2024.
For these audits, facilities will now be required to submit the following documents:
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Professional providers who use Availity® for claim submission now have access to the Quick Claims functionality for Highmark members. Quick Claims allows providers to create templates that pre-populate certain fields when submitting a CMS-1500 claim. This will save time for providers who routinely submit claims for the same patient or same service each week or each month. To learn more, go here.
To assist providers with claims submission for highly complex medical conditions, Highmark has created the Inpatient Facility Diagnosis Guidelines page on the Provider Resource Center (PRC) via Payer Spaces in Availity®.
Providers will find detailed information, including diagnostic thresholds and accurate coding guidance, on a variety of conditions, including Acute Respiratory Failure, Malnutrition, and Sepsis and Septic Shock. To view the Special Bulletin, click here.
As we continue to align with Highmark processes, the Primary Care Physician (PCP) Change form — which allows you to remove/add a member to your practice with the member’s consent — is being discontinued. Members are responsible for selecting their own Primary Care Physician, and they can do so in two easy ways by:
