Highmark medicare reconsideration form

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Our Healthcare Facilities. AIM Specialty Health. BlueCard Program. Braven Health. Braven Health Supportive Care Program. Case Management. Chronic Care Program. Horizon Behavioral Health. Horizon Care Home. Horizon Supportive Care Program. Medical Injectables Program. Our Pledge. Patient Health Support. Pharmacy Programs. Recognition Programs and Partnerships. Risk Adjustment Overview. Self Service.

Surgical and Implantable Device Management Program. Value-Based Programs. Demographic Updates. Utilization Management. Clinical Practice Guidelines. Cultural Competency. Educational Webinars. Network Specialists. Provider Self-Service Tools. Provider communications resources. View our Medicare Advantage page or individual plans page for additional appeal forms. Policy reconsideration - Request reconsideration of a coding policy.

Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim. For more details, see our corrected, replacement, voided, and secondary claims section. Support document cover sheet - Submit medical records or other required supporting documentation to process a claim. Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident. Other coverage questionnaire enrollment - Provide information about a patient's other healthcare coverage.

Balance billing protection act dispute — Providers or facilities not contracted with Premera can submit a balance billing dispute request.

The form must be received by Premera within 30 days from receipt of the original payment notification. Find out more about the Balance Billing Protection Act. Overpayment notification - Notify Premera of an overpayment your office received.

Use this form for your documentation purposes. Admission notification and discharge notification. Learn more about submitting prior authorization , including for DME.

General prior authorization request. Out-of-network exception request - Request in-network benefits for an out-of-network service. Durable medical equipment DME. Total joint replacement exception request - Specific to Washington small group members requesting a provider or facility that isn't a Premera-Designated Center of Excellence for total knee or hip replacement.

Pharmacy pre-approval request. Opioid attestation — Specific to School Employees Benefits Board SEBB members undergoing active cancer treatment, hospice, palliative care, end-of-life, or medically necessary care who might be exempt from quantity limits. For expedited authorization codes, call Premera pharmacy services at ProviderSource is free and requires:.

View our practitioner credentialing checklist or the Join Our Network page for more information. Behavioral health specialty addendum - Provide us with your behavioral health primary areas of clinical expertise. Dental provider credentialing application — Request to join our dental provider network. Provider update - Email this form to Premera with new information or changes to your current practice or payment structure.

The federal No Surprises Act requires health plans to verify all provider directory data every 90 day. It also requires all providers and facilities submit this information to in-network plans.

Unverified providers may be removed from our directory. Email us your completed documents. The credentialing process typically takes 30 days.

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Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Provider Information Management Forms. Electronic Forms Electronic Forms are submitted directly to Highmark via this website. Request for Assignment Account - Please use this form when you need to create a billing account for your practice.

Addition Request to Existing Assignment Account — Please use this form when needing to update practitioners affiliation to existing assignment account information. Contract Upload Form Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned. Please use this form to indicate your DEA status. Return from Leave of Absence Form Please complete this form when the provider is returning from a leave of absence.

This will allow for the reinstatement of network participation. Request to be a Highmark Professional Pennsylvania Participating Provider - Please complete this form to have a Highmark Professional Pennsylvania Participating Provider contract sent to your billing practice.

This form is for providers who are already enumerated. This form may not be used to terminate an individual commercial network. It may only be used to terminate the groups of networks listed above. If this information is not on file with Highmark Blue Shield, reimbursement will be 50 percent of the approved allowance, in accordance with our existing policy.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization.

Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Provider Information Management Forms. Electronic Forms Electronic Forms are submitted directly to Highmark via this website.

Request for Assignment Account - Please use this form when you need to create a billing account for your practice. Addition Request to Existing Assignment Account — Please use this form when needing to update practitioners affiliation to existing assignment account information.

Contract Upload Form Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned.

Please use this form to indicate your DEA status. Return from Leave of Absence Form Please complete this form when the provider is returning from a leave of absence. This will allow for the reinstatement of network participation.

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Changes to these elements will not be accepted via any other electronic form. Contact Us. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern 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. Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies.

Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Provider Information Management Forms. Electronic Forms Electronic Forms are submitted directly to Highmark via this website. Request for Assignment Account - Please use this form when you need to create a billing account for your practice. Addition Request to Existing Assignment Account — Please use this form when needing to update practitioners affiliation to existing assignment account information.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization.

Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Provider Information Management Forms. Electronic Forms Electronic Forms are submitted directly to Highmark via this website. Request for Assignment Account - Please use this form when you need to create a billing account for your practice. Addition Request to Existing Assignment Account — Please use this form when needing to update practitioners affiliation to existing assignment account information.

Contract Upload Form Please only use this form to send Highmark a contract. Other uploads will not be processed and not be returned. Please use this form to indicate your DEA status. Return from Leave of Absence Form Please complete this form when the provider is returning from a leave of absence. This will allow for the reinstatement of network participation.