Pittsburgh, PA 15230. If a provider or our employee was rude to you, If you feel a provider or we did not respect your rights as a member of our plan, If you have a problem with the quality of care or services you have received, If you have trouble finding or getting services from a provider, Your name and member ID number (found on your Health Options ID card). If we agree that you should get an appeal decision faster, you will receive a decision within 72 hours after Highmark Health Options receives your request.. 800 Delaware Avenue, Wilmington, DE 19801 Highmark Health Options review the latest Highmark Health Options Prior Authorization List. Clinical Provider Appeals are cases that are denied due to lack of prior authorization or denied based on medical necessity. New Castle, DE 19720 You or your representative will receive a letter from the State Fair Hearing ofcer that will tell you the date, time, and location of the hearing. Legal Information. Call Member Services for a translator. You can contact us at: Appeals & Grievance PO Box 106004 Pittsburgh, PA 15230 1-844-325-6251 When should I file an appeal? NaviNet seamlessly integrates all insurer-provider transactions into one system, such as inquiries on referrals/authorizations, eligibility, benefits, claims status, claims investigations, codes, and provider/facility searches. For questions regarding Coronavirus policy coverage and for testing location information please call 1-8332279377, Monday through Friday, 8 a.m. 6 p.m. You or your representative may submit additional information and may ask to look over all documents for the appeal. Contact Provider Services. Our network providers and other health care professionals are our partners in the delivery of high-quality health care services to our members. Providers - Contact Us | Highmark BCBSWNY Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. You or your representative may contact an appeal coordinator at any time for help or any questions about the grievance or appeal process. Highmark Health Options is an independent licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield Plans. The free, anonymous search feature can help you and your patients find care, education, food, housing, legal, money, work, and more. Highmark Blue Shield Provider Resource Center (Central, Eastern and Northeastern PA) CGI Call Center for Highmark Phone number: (877) 817-5954 Mon-Fri 8:00 a.m. to 5:00 p.m. EST E-mail Address: Highmark.helpdesk@cgi.com Fax - Medical Records: (216) 687-4249 Fax - Appeals / Additional Info: (216) 685-9418. Highmark Provider 7) Can you explain the credentialing process? Contact Us. If a Member needs these services, the Member should contact the Civil Rights Coordinator. You may request a State Fair Hearing instead of or in addition to ling an appeal with us. This letter will tell you that we have received your appeal. But if you need to contact us, here are the phone numbers exclusively for providers: PROVIDER SERVICE CENTER 1-800-543-7822. DSP Recruitment and Retention Payments Templates (ZIP). 1901 North DuPont Highway CoverMyMeds helps patients get the medication they need to live healthy lives by streamlining the prior authorization (PA) process for providers and pharmacists. If you need help ling a grievance, understanding the grievance process, or need help getting information for us to review, please contact Member Services at 1-844-325-6251 and ask for a Member Advocate. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. How do I continue getting services during the State Fair Hearing process? Call 1-866-488-7469 TTY: 711 (Monday - Sunday 8:00 a.m. to 8:00 p.m. EST) to talk to a representative who can answer questions about our plans. Providers Do not use this mailing address or form Highmark Blue Cross Blue Shield West Virginia Help you get additional information from your doctor to help with your appeal or grievance. Providers - Contact Us | Highmark Blue Shield of Northeastern New Highmark NaviNet-enabled providers are expected to use this tool for all routine eligibility, benefits and claim status inquiries. Highmark West Virginia has established a Provider Advisory Committee (PAC) to afford providers a mechanism to offer recommendations and comments to the Plan on provider billing, coding, and administrative issues. You will get a letter from us within five working days after your appeal. When you file your grievance, here are the things you should include: You can send or attach any documents to the Member Grievance Form that will help us look into the problem. 6) Who may I contact at Highmark Blue Cross Blue Shield Delaware (Highmark Delaware) for additional assistance? Select Language ; Select Language; Font size dropdown. If we extend the timeframe, we will send you a written notice of the reason for the delay. Authorizations Required for OOA and OON Musculoskeletal, Genetic Testing, and Radiation Oncology Services, Reimbursement Update: Daily Maximum to Increase for Therapy Services, Diabetes Distress: A Common, Under-Treated Emotional State, Prior Authorization No Longer Needed for Glimepiride and Glyburide. For TDD/TTY services, please call 1-800-480-1419. PO Box NaviNet is a free, Internet-based application for providers to streamline data exchanges between their offices and Highmark. You or your representative can also le a grievance in writing or by lling out a Member Grievance Form (PDF). To speak to a NaviNet Customer Care Representative directly, please call during the hours listed above at 1-888-482-8057. 1) What is Electronic Data Interchange (EDI)? Highmark Health Options Community Support connects those in need with local programs, resources, and support to help members navigate health care choices. The committee members have not been involved with the issue of your appeal. Fax your request forall member appeals or grievances to 1-833-841-8075. A State Fair Hearing is an appeal process provided by the State of Delaware. After you le a grievance, you will get a letter from us within ve working days. PO Box 106004 Attn: Claims Review This letter will tell you that we have received your grievance. You may choose someone to act on your behalf. If you suspect fraud, contact Highmark's Financial Investigations and Provider Review (FIPR) Department. Highmark Blue Cross Blue Shield West Virginia > Providers > Highmark Provider Help you through the appeal or grievance process. A decision letter will be mailed to you within 30 days from the date you led your appeal or within ve days of the decision, whichever is sooner. One of our friendly representatives is available to take your call. You can download a PDF of the Provider Directory HERE. If the decision was in your favor, Health Options will arrange for these services right away. Provider Highmark Health Options Call Member Services who will help you file your grievance. 8) What is Highmark Delaware's Holiday Schedule? FIND A DOCTOR OR PHARMACY. Our commitment to partnering with our participating providers is vital to providing quality coverage for our members. Addiction and Substance Use Disorder Resource Center. You, your representative, or doctor can request a fast appeal orally or in writing. If you would like a paper You receive the State Fair Hearing decision. A provider may submit an issue for consideration by the PAC by sending written comments, either by letter or email, to: Medical Director, c/o Manager of Operational QI You or your representative must file your appeal within 60 days from the date of the Notice of Action letter. You can get more information by clicking on the Electronic Data Interchange (EDI) Services link in the Claims, Payment & Reimbursementcategory on the left menu. This letter will tell you the reason for our decision and further appeal rights including your right to ask for a State Fair Hearing (see What should I do to get a State Fair Hearing below). This letter will tell you the reason(s) for the decision. Please call the number on the back of your member ID card 8:00 AM - 8:00 PM 7 days/week. You, your representative, or doctor can also file an appeal by mail. Below are several new tools and resources to help make your experience with Highmark Health Options successful. 40 Century Hill Drive. Not a Highmark member? Your right to appoint a representative to act on your behalf. Home page. Request a Call to talk to a Highmark licensed representative about our non-Medicare plans or to enroll. Not a Highmark member? Call 1-866-488-7469 TTY: 711 (Monday - Sunday 8:00am to 8:00pm EST) to talk to a representative who can answer questions about our plans. You or your representative may extend the timeframe for decision of the appeal up to 14 days. Highmark is a registered mark of Highmark Inc. {currentyear} Highmark Inc., All Rights Reserved. If you are a Highmark plan member with questions about your coverage, call the member service number on the back of your insurance card (hours vary depending on plan). Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. After a decision is made, a decision letter will be mailed to you. If you or your representative are not happy with the a denial in the Notice of Action or an appeal decision, you may request a State Fair Hearing within 120 days of the date on the Notice of Action or appeal decision letter. WEST VIRGINIA FAMILY HEALTH INFORMATION 1-855-412-8001: Provider Services You le for a State Fair Hearing on or before the effective date of the proposed action. Refer to the Member Handbook for more details about benefits and covered services. A grievance does not include a denial of benefits for health care service. Pittsburgh, PA 15222-3099 Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Attn: Clinical Provider Appeals If you want to have someone le a grievance or appeal or represent you, we will need to have your OK in writing. Hours of operation are 8:00 a.m. to 4:30 p.m. EST Back to Top How can I reach Customer Service by U.S. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Call Provider Services at 1-844-325-6251, Monday through Friday, 8 a.m. 5 p.m., or contact your Provider Account Liaison. It will include information about the grievance process and your rights including: Your grievance will be reviewed by one of our staff members who has not been involved with your grievance but knows the most about your issue. The hearing can be held in-person or by telephone. Site Map. However, if it becomes necessary for the Committee to discuss personally identifiable health information or proprietary information, all non-PAC members except Highmark West Virginia employees will be excused from the meeting prior to the discussion of such information, in order to comply with federal and state privacy requirements or to protect proprietary information of the Plan. Start today by creating a free account, or logging in to your existing account at CoverMyMeds.com. Box 1353 Charleston, WV 25325 Email: pac@highmark.com Phone: (304) 347-7681 Please Your phone number Your address What are you appealing? Contact Our vision is to ensure that all members of the community have access to affordable For more information, call Provider Services at 1-844-325-6251 MondayFriday, 8 a.m.5 p.m. 800 Delaware Avenue, Wilmington, DE 19801. Do not use this mailing address or form to report fraud. A grievance can be about any service that you received from a doctor or by us. We may also extend the timeframe for decision up to 14 days if additional information is necessary and the delay is in your best interest. We may also extend the timeframe for decision of the grievance up to 14 days if additional information is necessary and the delay is in your interest. Welcome to the Highmark Provider Portal. 1-302-255-9500 or toll-free at 1-800-372-2022. Highmark Health Options and the network of providers give work together to give high quality health care to those who need it most: adults and children eligible for Medicaid and medical assistance. Back to Top. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. Your right to review or request a copy of all documentation regarding the grievance upon request free of charge. Provider Disputes are requests that are not regarding medical necessity rather are administrative in nature such as, but not limited to, disputes regarding the amount paid, appeals of denials regarding lack of modiers, refunded claim payments due to incorrect payment or coordination of benet issues. Authorizations Section Added to Provider Resource Center, Authorization Letters Available in NaviNet for Inpatient Services, New Go-Live Date! Contact Us | Highmark Medicare Solutions If we extend the timeframe, we will send you a written notice with the reason for the delay. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Please note that if your representative or doctor files an appeal for you, you cannot le a separate appeal on your own. ENR-332 (10-19) WHB/WN-DP-O Page 2 of 12 providers will accept the Plan's payment plus the member's total liability as Tools and Resources for Non-UCD Members. The contents of this list are subject to change in accordance with plan policies and procedures and the Provider Manual. 2) How do I begin using EDI to submit claims electronically? Provider Directory. Highmark You may also ask for help with a grievance or appeal by calling Member Services and asking for a Member Advocate. [{"id":37634,"versionId":87,"title":"State of Delaware Extending Highmark Medicfill Supplemental Plan for Medicare Retirees for 2023","type":4,"subType":null,"childSubType":"","date":"11/4/2022","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"urlText":null,"description":"\u003cp\u003eFor 2023, State of Delaware benefit-eligible Medicare retirees and dependents will continue coverage under Highmark\u0026rsquo;s Special Medicfill\u003csup\u003e\u0026reg;\u003c/sup\u003e Medicare Supplemental plan. We are committed to providing outstanding \u003cstrong\u003e\u003ca href=\"https://content.highmarkprc.com/Files/Region/hdebcbs/NewsletterNotices/SpecialBulletins/sb-state-of-delaware-retirees-moving-to-highmark-medicare-advantage-plan.pdf\" target=\"_blank\" rel=\"noopener noreferrer\"\u003eClick here\u003c/a\u003e\u003c/strong\u003e for more information.\u003c/p\u003e","visible":false,"archive":false,"liveStatus":2}], Chapter 3, Unit 2: Professional Provider Credentialing. Standard Rates for medical specialty drugs and injections are reimbursed at the Average Sale Price (ASP) minus 6%. An Appeal Committee will review your appeal and make a decision. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. What do you want as a result of your appeal? Please be sure to include your own contact information in case Highmark West Virginia or the PAC need to contact you for additional information. Box 1353 Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Phone Number of Highmark Bcbs is +1-877-298-3918, 1-800-294-9568 . If you, or someone you choose, are unhappy with the State Fair Hearing decision, you or your representative can ask for a judicial review in Superior Court. Enter your zip code, click on the plan name and select Provider/Pharmacy Directory, then click Download. A decision letter will be mailed to you within 72 hours after Highmark Health Options receives your request. BCBS Provider Phone Number - Anthem Blue Cross and Blue Shield What should I do if I need a decision faster than 30 days? Latham, NY 12110. Contact Us | Highmark The original time period covered by the original authorization has not run out. PO Box 106004 We have failed to give you timely service. If you file your appeal by phone, you must also put your appeal request in writing within 30 days of calling Member Services. This page is not available for this ZIP code. Find help today. TTY users It will also include information about the appeal review process. 5am to 3am. Highmark Blue Cross Blue Shield TTY: Dial 711. We may also extend the timeframe for decision of the appeal up to 14 days if additional information is necessary and the delay is in your best interest. You or your representative may extend the timeframe for making the appeal decision for up to 14 days. Provider Highmark Contact Information - Highmark Blue Shield Do not use this form to ask questions about your health coverage or to provide confidential personal health information. Use the online Prior Authorization Lookup and search by codes or review the latest Highmark Health Options Prior Authorization List. P.O. Providers in need of assistance should contact provider services at 800-241-5704 (toll-free). A Member Advocate can: A grievance is a statement of unhappiness, like a complaint, and can either be led in writing or verbally over the phone. contact bcbs highmark If you were previously authorized and getting services that we are now terminating, suspending, or reducing, you may ask to continue getting services if: If we continue your services during the State Fair Hearing process, we will continue to cover these services until: It is important to know that you may have to pay for the services you received while your State Fair Hearing was pending if the nal decision is not in your favor. For busy clinicians, having access to the right tools and resources are important to help you and your staff streamline day-to-day tasks. At least three members will be selected from nominations submitted by the West Virginia State Medical Association. You, or your representative, may le a grievance at anytime. For anything else, call 1-800-241-5704 (TTY/TDD: 711) Monday through Friday 8:00 a.m. to 5:00 p.m. EST Have your Member ID card handy. Call Member Services for help or with questions about how to le an appeal or grievance. (TTY/TDD: 711). What can I do to continue getting services during the appeal process? Please reference the: HIGHMARK PROVIDER MANUAL: Chapter 3, Unit 2: Professional Provider Credentialingfor additional information related to the credentialing process and requirements. Highmark Blue Cross Blue Shield Health Options will also have a representative at a State Fair Hearing. 1-844-325-6251. Provider Find help for your patients based on unique needs and location. To submit a Clinical Provider Appeal, use the following contact information. If your doctor would like to discuss your appeal with one of our doctors, they may call us at 1-844-325-6251to speak with a medical director.
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