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What's happening?

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.

To do this, we will begin to integrate our claims-processing systems beginning November 2021.

Some workflows and policies will change as your patients gradually move to Highmark’s system. 

We appreciate your patience as we discover these new ways of working together. 

Note:
some of the services that Highmark will be providing are contingent on Department of Health approval, which we anticipate in near future.

Click here for some answers to frequently asked questions. 

Frequently Asked Questions (FAQs)

Updated September 16, 2022

AFFILIATION INFORMATION

What does this affiliation mean?

  • Highmark Blue Cross Blue Shield of Western New York has become an affiliate of Highmark Health
  • While we’ve become an affiliate of Highmark, our location and mission as a not-for-profit health plan will not change
  • Click here to view a message from our market president, Mike Edbauer, DO, on why this affiliation is happening

Will the company change locations?

  • No, we will remain a Blue, not-for-profit health plan based in New York state with a solid commitment to local provider partnerships
  • Highmark’s corporate headquarters is located in Pittsburgh, Pennsylvania but we will continue to maintain our local headquarters and strong community presence in Western New York

Will the company change its name?

  • Yes, we have changed our name to Highmark Blue Cross Blue Shield of Western New York

PHASED INTEGRATION/DUAL PLAN MANAGEMENT

How are you integrating your systems with Highmark? Will this happen all at once?

  • Beginning in November 2021 and throughout 2022, patients will be moved onto Highmark’s system gradually
  • The timeframe for these moves will be based mostly on each group’s or individual’s scheduled renewal date
    • Patients covered by the Federal Employee Program (FEP) will all move onto Highmark’s system for dates of service beginning November 1, 2021
  • On January 1, 2023 all patients will have been moved onto Highmark’s system, when Medicare Advantage, Essential Plan, individual markets and the last large group and ASO patients are moved over

During the phases of the transition, how will I know if my patient is in the legacy BlueCross BlueShield of Western New York system or on Highmark’s system?

  • Click here for guidance on how to know which system your patient is on
  • For patient ID cards that have the Highmark logo in the upper left-hand corner there are some differences:
    • Light blue back of ID card: indicates patients are still in the legacy BCBSWNY system
    • White on both sides of ID card: patients have been moved onto Highmark’s system
    • Gray back of ID card: indicates Medicaid and Child Health Plus patients
  • The surest way to know is by checking eligibility and benefits on HEALTHeNET, which will reflect real-time patient benefits

Please note: FEP members will be moved onto Highmark’s system beginning 11/1/2021, but their ID cards will not change

Are Medicaid and Child Health Plus (CHP) patients going to be moved to Highmark system?

  • Not at this time - they will continue to be managed by Amerigroup under existing procedures and policies
  • Beginning January 2022, you may start to see Medicaid/CHP ID cards with the Highmark BCBSWNY logo on the front, but the back of their card will be gray

Will I need to sign up for NaviNet?

  • Yes, you will need access to NaviNet for your patients as they are gradually enrolled onto Highmark’s system
  • 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 preauthorization 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(s) will be added as options for you under the My Health Plans menu after 11/1. If you don't see them as options in the My Health Plans menu, please follow these steps to request access
  • You will be able to access information about your patients who have transitioned to Highmark plans on NaviNet beginning on the patient’s effective plan date

How do I sign up for NaviNet?

  • If you are not currently registered with NaviNet to interact with another payer, we will let you know when NaviNet’s system is ready to take new registrations for our network providers
  • 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 to create an account
  • Click here to check your NaviNet registration status, if you think you are already registered with NaviNet for other payers

How do I enroll for electronic fund transfers (EFT)?

  • After registering with NaviNet, you must also enroll in electronic funds transfer (EFT) and paperless explanation of benefits (EOB) statements of 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?

  • You will need to maintain your banking information in both PaySpan and NaviNet until we have fully transitioned onto Highmark’s system
  • If you updated your banking information in PaySpan on or after October 25, 2021, you would need to update it in NaviNet as well
  • Once you register for NaviNet, you’ll be able to view and make changes to your banking information beginning November 1
  • Your designated NaviNet Security Officer will be able to electronically attest, register, and/or maintain banking information on behalf of your office

Where can I find guidance on using NaviNet?

ELIGIBILITY

How will I check eligibility for my patients on Highmark system?

  • For all patients, eligibility and benefits can still be checked via HEALTHeNET
  • You can also use NaviNet to check eligibility for patients enrolled onto Highmark’s system

How do I check eligibility if my patients don’t have their new Highmark ID card?

  • You may verify eligibility and benefits for ALL patients at HEALTHeNET as long as you have at least two of the following for your patient:
    • ID number
    • Date of birth
    • First and last name

Can I still call Provider Service to check eligibility? What number should I call?

  • We recommend checking eligibility on HEALTHeNET to save time and avoid wait times for Provider Service
  • If your patient does not have their ID card, you should check HEALTHeNET by providing your patient’s date of birth and first and last name
  • You can still call Provider Service at  1-800-950-0051

Please note: FEP Provider Service can be reached at 1-800-234-6008.

Why are less eligibility benefits being displayed on HEALTHeNET?

  • When checking a patient’s eligibility on HEALTHeNET you will need to select the service type to display that benefit (Example: if you’re checking eligibility for Durable Medical Equipment (DME), you will need to select that service)
  • For more information, review the HEALTHeNET tipsheet here

Why do I have to select a provider on eligibility?

  • Highmark’s eligibility process requires you to select a provider when checking eligibility
  • For more information, review the HEALTHeNET tipsheet here

PAYMENTS 

If I am currently enrolled in EFT through PaySpan, will my payments still come electronically for patients enrolled on Highmark’s system?

  • Yes, if you previously enrolled in EFT through PaySpan, you will continue to receive payments electronically
  • We enourage 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 for patients on both legacy and Highmark systems

Where should I go to check fee schedules for my patients?

  • Fee schedules will be the same for ALL patients, whether they are on legacy BCBSWNY or Highmark systems, so you can either check them by logging on at bcbswny.com/provider or on Highmark’s provider portal/NaviNet after 11/1

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

CLAIMS/BILLING 

How do I submit claims if my patient is on Highmark’s system?

  • Claims for all patients will continue to be submitted electronically through Administrative Services of Kansas, Inc. (ASK), for patients on either legacy BCBSWNY or Highmark’s system
  • Claims billed for date-of-service (DOS) after a patient has moved onto Highmark’s system must be billed with their NEW member ID or the claim could be rejected
    • You can use HEALTHeNET or NaviNet to check your patient’s effective date and eligibility and you should ask patients if they have a new ID card at the time of their visit
  • Paper claims for your patients on Highmark’s system can be mailed to:
    • PO Box 4208
      Buffalo, NY 14240-0080
  • NOTE: paper claims for patients still in our legacy system should be sent to:
    • PO Box 80
      Buffalo, NY 14240-0080

Can I bill using either a UB04 or CMS1500 form for patients on Highmark’s system?

  • 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
  • Click here 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 patients
    • Photocopies or outdated versions of the forms will be returned and will need to be resubmitted

How will Highmark’s claims processing system differ from your current ClaimsXten system?

  • Attention to proper coding and correct use of modifiers will continue to be key to avoiding payment delays or denials regardless of whether patients are covered by our legacy BCBSWNY plans or moved onto Highmark’s system
  • Highmark has its own claims-processing system and will conduct post-payment audits for Highmark BCBSWNY patients, so providers will likely see some differences in how claims are edited at Highmark
  • As patients gradually move onto Highmark's system, providers will have time to become familiar with Highmark’s system and their reimbursement policy we will adopt, which adheres 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 will your reimbursement policies change?

  • We have adopted Highmark’s reimbursement policies
  • As of 11/1, there are changes to reimbursement for some codes
    • Some codes that we traditionally have not reimbursed will become available for billing/reimbursement on 11/1
    • Some codes that were reimbursed in the past will no longer be reimbursed or will become “No Separate Fee” when billed as part of an office visit
  • 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?

  • Beginning January 1, 2023, we will be aligning with Highmark’s preventive services schedule determined by the USPSTF, AAP Bright Futures, HRSA Women’s Preventive Health, CDC General Immunization Schedule, and CMS Preventive Schedule
  • This means some labs previously considered preventive with a $0 cost-share for your Highmark Blue Cross Blue Shield of Western New York Commercial and Medicare Advantage patients will now be subject to your patients’ regular cost-shares and deductibles only when the lab is billed with a medical diagnosis

Preventive Labs

  • For your Commercial Highmark BCBSWNY patients, the following labs will be covered under preventive benefits with a $0 cost-share January 1, 2023:

Commercial Preventive labs for adults include:

  • Cholesterol/lipid screening
  • Glucose screening for screening for diabetes
  • Hepatitis B screening
  • Hepatitis C screening
  • Latent tuberculosis screening
  • Chlamydia, Gonorrhea, HIV, Syphilis screening
  • Overweight or obese BMI- hemoglobin A1c or glucose
  • PAP and HPV screening
  • PSA Screening

Commercial Preventive labs for children/adolescents include:

  • Lead screening
  • Anemia screening hemoglobin and hematocrit
  • Newborn blood screening and bilirubin
  • Cholesterol/lipid screening
  • Hepatitis B screening
  • Hepatitis C screening
  • Latent tuberculosis screening
  • Overweight or obese BMI- hemoglobin A1c or glucose
  • Chlamydia, Gonorrhea, HIV, Syphilis screening

Additional Commercial Preventive labs for pregnancy include:

  • Urine culture
  • Rh typing/antibody
  • Gestational diabetes screening
  • Syphilis and HIV screening
  • Hepatitis B screening

Commercial Diagnostic Labs

The following labs will be considered diagnostic and must include a medical diagnosis code beginning January 1, 2023. These labs will be subject to your patients’ regular cost-share.

Some of these labs may have previously been considered preventive with a $0 cost-share in 2022 but will no longer be considered preventive in 2023.

Please note: Labs no longer on the preventive schedule that are billed without a medical diagnosis code may be subject to full patient responsibility.

Diagnostic lab examples that must include a medical diagnosis code include:

  • TSH testing
  • CBC
  • CMP
  • Urinalysis
  • Vitamin D
  • HCG/pregnancy testing
  • FOBT (other than colorectal neoplasm screening)
  • Antibody testing
  • Hemoglobin A1c (for normal weight)
  • Diagnostic PAP smear
  • Vaginal infection tests

Medicare Advantage ONLY

For your Highmark BCBSWNY Medicare Advantage patients, some services have been added to the preventive schedule or have had a coding change.

The following services that have been added as a preventive service with a $0 cost-share for your Highmark BCBSWNY Medicare Advantage include:

  • Cervical cancer screening with Human Papillomavirus (HPV)
  • Colorectal cancer screening (Screening CT virtual colonoscopy and FIT Kit)
  • Pelvic exam (annual GYN exam)

The preventive services that have had a change in coding guidance include:

  • Bone mass measurements – code 78359 will no longer be considered preventive
  • Hepatitis C screening – codes 86803 and 86804 will no longer be considered preventive
  • For a complete list of preventive services and corresponding coding guidance, please visit the CMS Medicare preventive services schedule here

How do I make a claim inquiry/request an adjustment for patients on Highmark’s system?

  • To see how a claim was processed and why (known as “provider inquiry” in HEALTHeNET), you can submit a Claim Investigation Inquiry in NaviNet
  • For patients still covered on the legacy BCBSWNY system, please continue the usual provider inquiry process through HEALTHeNET

Please note: Electronic claims investigation requests should be available through NaviNet for FEP members beginning 11/1/2021 

How can I check claims status?

  • For ALL patients, claims status can continue to be checked on HEALTHeNET
  • When patients move to Highmark's system, you can also review detailed claims information, check claim status, and launch a claims investigation through NaviNet’s Claim Status Inquiry tool

Are there any changes to the way I need to submit provider information on a claim?

  • Yes, 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
      • Dr. Jane Doe submitted in Rendering Provider Loop 2310B
    • CMS1500 Paper Billing Guidelines
      • Provider Group ABC submitted in Billing Provider Box 33
      • Dr. Jane Doe submitted in Rendering Provider Box 24J

Will there be 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”
      • Attending 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

Will there be 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)
        • Psychologists
    • 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 for migrated members. 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

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 on their ID card

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.

MEDICAL COVERAGE POLICIES/PREAUTHORIZATION

Will there be different/new processes for preauthorization requests?

Note NaviNet preauthorization process exceptions:

  • Preauthorizations for radiation therapy for all ASO/self-funded patients will continue to be submitted by completing this preauthorization form and faxing to the number on the form
  • Preauthorization requests for high-end imaging and radiation therapy services will continue to be sent to NIA Magellan for your legacy BCBSWNY patient

Which preauthorization requirements will change?

  • When patients move to Highmark’s system, you will use the NaviNet electronic portal for requesting preauthorization requests; there are also phone and fax options (see below).

We will adopt Highmark's preauthorization requirements as patients move onto Highmark's system. Differences are as follows:

Medical/DME

Medical Injectable Drugs

Behavioral Health

  • For behavioral health, there will be no changes to which services require preauthorization 

Please visit Highmark’s Provider Resource Center at hwnybcbs.highmarkprc.com and click “Requiring Authorization” on the ribbon at the top of the page to check if a procedure or medication code requires preauthorization when a patient moves to Highmark's system (Exception: Home Healthcare codes, which will NOT require preauthorization). 

Are there phone and fax options for preauthorization requests in addition to electronic submission options?

  • Yes, authorizations can be submitted by fax for all patients. Fax forms for Highmark system patients are available in the Provider Resource Center under the “Forms” tab on the left.
  • Fax and phone numbers for Highmark system patients are:
    • Phone:
    • Fax:
      • 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

Are you changing medical protocols for patients on Highmark’s system?

  • Yes, all plans vary somewhat on medical policy, so it’s to be expected that you will see some variation as your patients start to move over to Highmark’s system
  • For patients transitioned to Highmark's system, you should review the Highmark medical policies we will adopt by visiting hwnybcbs.highmarkprc.com and clicking on the Medical Policy Search bar at the top of the page
    • Click on Highmark Commercial Medical Policy – New York
    • The Site of Care Policy: Through the duration of 2022, all contracted New York facilities will be designated as approved sites for Medical Policy I-151: Site of Care Policy. If a medication is requested to be administered at a facility outside New York’s contracted facility list, Medical Policy I-151 criteria will apply. 

Will patients on Highmark’s system need to get preauthorization for Home Healthcare?

  • While we originally announced that Home Healthcare would require preauthorization, we have put this decision on hold until further notice.

Will providers with “goldcard” privileges still be able to use the notification process instead of requiring preauthorization?

  • Yes, goldcarded providers will submit an electronic request through NaviNet, which will be auto-approved once the request is sent via NaviNet to eviCore
  • eviCore will have the list of gold-carded providers and will recognize when requests should be automatically approved

If I have an existing authorization in place, will I need to resubmit the request through NaviNet?

  • No, you’ll be able to view current authorizations in NaviNet once your patients move onto Highmark’s system

PHARMACY 

How will pharmacy coverage change?

  • Express Scripts will continue as our pharmacy benefits manager for Commercial and Medicare Advantage patients
  • However, as patients move to Highmark's system, we will adopt their formularies, so covered/tiered medications may differ somewhat from what you’re used to
  • We always recommend checking pharmacy benefits for your patients before making prescribing decisions
  • Go to hwnybcbs.highmarkprc.com and click on the Formulary Information button to check formulary coverage for your patients transitioned 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 patients will continue to be covered through CVS Caremark for retail pharmacy and mail order.

How do I request medication preauthorizations and non-formulary requests?

  • In-office medical injectable preauthorization for patients on Highmark's system can be submitted via NaviNet or by faxing requests to 1-833-619-5745
  • Pharmacy medication preauthorization 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 preauthorization request option
    • You can also call them at 1-866-452-5017 to get help with registration or using Cover My Meds for preauthorization
    • We will adopt Highmark's pharmacy preauthorization requirements as patients move to their system
    • To check which medical drug or NOC (not otherwise classified) codes require preauthorization, please visit hwnybcbs.highmarkprc.com and click Requiring 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 preauthorization) 

How do I handle patients who have Medicare Part-D coverage?

  • All Medicare Advantage patients will remain in the legacy BCBSWNY system and covered by Medicare policies and processes until 1/1/2023

Will Accredo continue as the specialty pharmacy provider for patients?

  • Yes, Accredo will be the preferred specialty pharmacy for at-home/patient administered benefits
  • There will be some changes to medication coverage, so please check our new policies which can be found at Highmark Pharmacy Policy search before prescribing for patients on Highmark’s system
    • 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)

Are there any changes to claims/billing for medical (in-office) drugs?

  • There will be 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 for patients on Highmark's system
  • 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
  • Please visit hwnybcbs.highmarkprc.com and click on the Pharmacy Program/Formularies button to review the “List of Procedure Codes Requiring NDC Information” for patients on Highmark's system

PROVIDER SERVICE/SUPPORT

Can I continue to call my practice account manager 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
  • You will hear new prompts that are designed to help us direct your call to the team member best able to answer your questions depending on which system your patient is on (Highmark or legacy)
  • Please understand that our team members will do their best to help you and get to your call as quickly as they can while we switch between systems 

Will providers still be able to get patient/population health data from Risk Manager?

  • Yes

How do I refer patients into Care and Disease Management programs once they are on Highmark’s system?

  • Patients enrolled on Highmark’s system can be referred into Care Management programs electronically through NaviNet
  • You can still use Care Affiliate or call Health Care Services at 1-877-837-0814 to refer legacy BCBSWNY patients

Where can I find more information about Highmark’s policies and processes for my patients who have moved onto Highmark’s system?

UTILIZATION MANAGEMENT

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
  • Fax:
    • 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 for patients on Highmark’s system. 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's system
  • Authorization letters will be sent to facilities throughout a patient’s stay
  • Post-Acute Care Facilities can also use phone or fax
  • Phone: 1-844-946-6263
  • Fax: (Medical inpatient) 1-833-581-1868

CONTRACTING

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
  • We anticipate transitioning providers from individual provider agreements into group practice agreements beginning around year end
  • While this may be an inconvenience for providers in the short term, we believe it will be simpler going forward
  • Existing groups with a Group Practice Agreement (GPA): if the provider is part of a group that is contracted at the GPA level, the provider will automatically become affiliated with the group’s provider networks once the provider has successfully completed the credentialing process; no further contracting will be needed
  • New groups/a new provider with a group that is not contracted under a GPA: the provider will be affiliated with the group and sent a GPA once the provider has successfully completed the credentialing process; once the GPA has been signed and received by Highmark, the provider and group will be affiliated to all appropriate provider networks under the GPA
  • 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

CREDENTIALING

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, click here
     

OTHER

Will Quest continue as preferred lab provider?

  • Yes

Will Landmark continue to support your Care at Home program?

  • Yes

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

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