Updated Highmark Policies Include New Medical Review Process for Incorrectly Coded Claims

Last Updated: May 29, 2019

Claim_computer_keyboard-articleHighmark has announced several recent policy updates including:

  • The implementation of a new medical review process for claims that are not coded correctly
  • A new option for self-insured employer group plans
  • Changes to reimbursement for venipuncture (blood draws)

Here is a closer look at these changes.

Medical Review Process for Incorrectly Coded Claims and for Modifiers 54 and 55

Effective June 1, 2019, Highmark is implementing a more thorough review process for claims that are not coded correctly prior to finalization. Highmark will be using data analytics to reinforce these policies:

  • Modifiers 54 and 55 – This policy addresses the co-management of surgical procedures with a 10- or 90-day global period. Physicians who perform surgery and furnish pre- and post-operative work should bill for global surgical care using the proper CPT surgical code and should not bill separately for visits or other services included in the global package. If a physician must transfer care during the global period, modifiers 54 and 55 are used to distinguish who is providing care.
  • Correct Coding Guidelines – This policy addresses medically unlikely situations, similar codes which may be clinically duplicative which occur on the same day, and appropriate use of codes which represent a combination of two or more components.

When additional information is needed to finalize a claim, Highmark will send notification by letter. You must return the requested information within 30 days. If medical records are requested but not received, the claim or service will be denied.

If a claim is denied, you will be notified by letter. To appeal the decision, you must provide documentation or an explanation specific to the reason for the denial for the claim to be reconsidered.

For more details, you can review Highmark’s ebulletin on the medical review process.

New Option for Self-Insured Employer Groups

On May 1, 2019, new coverage options for self-insured employer groups took effect for the Community Blue network in Western Pa. and the Premier Blue Shield Network in Central and Northeastern Pa.

You can identify plan members by these plan names and alpha prefixes:

  • JII – Central PA Community Blue Premier Flex PPO
  • JII – Central PA Community Blue Premier Flex EPO
  • JIJ – Central PA PPO Blue
  • JIJ – Central PA EPO Blue
  • JIK – Community Blue PPO
  • JIK – Community Blue EPO

Member ID cards for these plans will include additional contact information for third party administrators (TPAs) who handle certain service areas. Providers will receive two remittances from Highmark—one for regular business and one related to TPA business.

Highmark offers more details, including which services are handled by Highmark and which are handled by TPAs, in this e-bulletin on self-insured employer groups.

Venipuncture Not Reimbursed When Billed with Lab Services

As of May 6, 2019, Highmark is no longer reimbursing for outpatient venipuncture (blood draws) when billed with another blood or serum lab service on the same date of service, by the same provider and for the same patient. Highmark says it considers the venipuncture to be incidental to the lab test and therefore not eligible for separate reimbursement.

You can find more details on in this Highmark e-bulletin with venipuncture reimbursement guidelines

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