below, have been tried and have not resulted in significant improvement: Non-steroidal,
An indication or a diagnosis of pain may qualify as functional impairment. Medicare Highmark Medicare dropdown expander Highmark Medicare dropdown expander. considered medically necessary when functional impairment exists and
(dermatitis occurring on opposed surfaces of the skin, skin irritation,
Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2319543749. of inverted nipples is
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. Hair transplant is considered cosmetic and, therefore, non-covered for any other indication. Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service. several websites with calculators to assist in calculating body surface area,
Learn more. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2304326090. x9`D/c\(9;FzesU'*~}bS|
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Hair removal is considered cosmetic and, therefore, non-covered for any other indication. the following criteria are met: Nipple
Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Provider Webinar: Submitting Electronic Inpatient Authorizations. (u2-4/UA|~ ? Highmark Blue Cross Blue Shield, H ighmark Senior Health Company, and Highmark Choice Company a re independent licensees of the Blue Cross and Blue Shield Association . Provides free aids and services to people with disabilities to communicate effectively with us, such as: Written information in other formats (large print, audio, accessible electronic formats, other formats). Rhytidectomy (Meloplasty, Face Lift) may be considered medically necessary when functional impairment
For more information, please refer to Chapter 3, Unit 5 of the Office Manual. Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Payment Policies. L5 n]SS358{n% Tn-nIN98 .XR|:Dg Bg/Vb:l?qbO[]/Ko]=lmb'{_'>Yd[w'~->;N][qa'%%"(9Q'7a'oO>7l/rCrO02_H"JD5r("',#/Xyp5}4}_uS`M5'IxkQYf0#3rR$>
o9/w! You can also receive a paper copy of your SBC (s) free of charge upon request. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
see the table attachment at the end of the policy for the Schnur Table. For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. Claims and Payment Policies. Take the PA-100 N. exit-exit number 14B-towards Fogelsville.
non-seasonal submammary intertrigo; Significant
200 Independence Avenue, SW
Once you download it, sign up or use your same login info from the member website and bingo! greater than or equal to 18 years of age. Refer to Medical Policy S-55, Surgical Treatment of Varicose Veins, for additional information. Last updated on March 16, 2022. Procedures/products/services via any treatment modality (e.g., laser,
indication. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements. Non-Covered Diagnosis Codes for Procedure Codes 17000, 17003, 17004, and 96900. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. Freedom Blue PPO is a Medicare Advantage Preferred-Provider Organization that gives you coverage for every need - health, prescription drugs, routine dental, vision, hearing and preventive care. Learn more. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator. Repair of a defect that does not result in a bilobe earlobe (e.g., a large hole resulting from wearing heavy jewelry) is considered cosmetic and, therefore, non-covered. Medical policy coverage guidelinesare developed and maintained in accordancewith all applicable laws and regulations, standards of regulatory and accreditation agencies such as NCQA and the national Blue Cross Blue Shield Association (BCBSA). SAMPLE OF A MEMBER ID CARD 1. . Discrimination is Against the Law You can also e-mail 1099inquiry@highmark.com. Manipulation (98925-98929, 98940-98943 . NOTE: Surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed may be considered medically necessary. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Under standard Highmark contracts, manipulation of the spine is a non-covered service and should be denied. pharmacologic therapy, specific for the treatment of rosacea, has failed or is
We are committed to providing outstanding services to our applicants and members. revision treatment is considered cosmetic and, therefore, non-covered for any
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If preferred, there are
Cryotherapy (e.g. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state. They are based on objective, credible sources, such as the latest scientific literature and citations, guidelines from nationally recognized health care organizations, evidence-based consensus statements, and expert opinions from our medical directors. Refer to Medical Policy Bulletin Y-1 for information on Dry Hydro Massage. Rhinoplasty
considered cosmetic and,
Input your Medical Policy search words. Medical decision making 15.2 ! 18 years old will be considered on an individual basis, due to the
SAMPLE OF A MEMBER ID CARD 1. For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. Pre-Approvals Not Required for Authorizations Submitted Between 8/22 - 10/3*. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Highmark Choice Company, Highmark Senior Health Company, Highmark BCBSD Inc. and Highmark Senior Solutions Company are Medicare Advantage plans with a Medicare contract. Freedom Blue PPO. If there are no procedure specific guidelines associated with a
Reporting Fraud Do not use this mailing address or form to report fraud. an attempt to restore the ability to breast feed. To access all of the features on the Highmark Plan App, you must have active Highmark medical coverage. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. resulting from an accident or when functional impairment exists. You can file a grievance in person or by mail, fax, or email. Provides free aids and services to people with disabilities to communicate effectively with us, such as: If you must submit a telephonic request, call the appropriate phone number below to reach Medical Management & Policy: Western Region: 1-800-547-3627 546 0 obj
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. x]r8\&@V%qNfg.dI9#KI`|F$@R$hwj"KTnt7?tr^VdLN&_OE>|9['dAw{! 906 0 obj
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Y0037_19_1662_M Accepted Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. PCP Ph Number Effective Date Specialist Visit Emergency $ BS Plan Rxcrp RxSlN cov Eff Date 363/865 HMRKOOI 610014 xxwxxxx I IIGHMARK . !^/k#^Wah
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?rj{F@[Li+T.6h3L$J_5r_Va2Z19V}zF\FV`-j(aX_nR}Q@ s cmGK1&MQxpLYf"ir] Otoplasty is considered cosmetic and, therefore, non-covered for any other indication. Evaluation and management services 15.1 ! Washington, D.C. 20201
is considered cosmetic and, therefore, non-covered for any other indication. Gynecomastia in individuals less than 16 years of age generally will resolve on its own. 800 Delaware Avenue, Wilmington, DE 19801. ust be 18 months postoperative following bariatric surgery. Volume 63, Number 4, 04/2006. Learn more. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2223070316. If you have an account, you can log in to check the status of your application, find information about your plan, and see what happens next.
Get the Highmark Plan App. All rights reserved. Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Highmark Reimbursement Policy Bulletin Bulletin Number: RP-047 Subject: Venipuncture and Lab Services Effective Date: May 6, 2019 End Date: Issue Date: November 1, 2021 Revised Date: July 2021 Date Reviewed: July 2021 Source: Reimbursement Policy Reimbursement Policy designation of Professional or Facility application is based on how the provider is contracted with the Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met. If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Abdominoplasty, Panniculectomy (Tummy Tuck) may be considered medically necessary when ALL of the following criteria are met: NOTE: The individual must be 18 months postoperative following bariatric surgery. These services require medical review prior to payment. is a monthly newsletter for the health care providers who participate in our networks and submit claims to Highmark using the appropriate HIPAA transactions or claim forms as required by Highmark. 10/13/2022. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. They are intended to reflect reimbursement and coverage guidelines. To access an SBC, please choose a plan from the list above. Nipple Tattooing may be considered medically necessary when ANY of
Highmark Health Options provides coverage under the medical benefits of the Company's . For plans purchased on the Health Insurance Marketplace please call 1-888-510-1084 . c2F:AU$K$k3svciPCd1b9*F
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is considered cosmetic and, therefore,
When performed as part of a reconstructive procedure following radical
Back, neck or shoulder
Call 1-877-298-3918. Refer to Medical Policy S-184, Gender Reassignment Surgery, for additional information. Abdominoplasty and/or panniculectomy are considered cosmetic and, therefore, non. xP / aV 0]E pKfWERQ ?F5*Oa\+U3;Qp@T *
hBhC Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state. If you need these services, contact the Civil Rights Coordinator. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. x=r8 endstream
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Appropriate
Ancillary Services Anesthesia Consultations Dental Diagnostic Medical Durable Medical Equipment Injections Laboratory Maternity Miscellaneous Orthotic & Prosthetic Devices Podiatry Radiation Therapy & Nuclear Medicine Radiology Surgery Therapy . All references to Highmark in this document are references to the Highmark company that is providing the members health benefits or health benefit administration. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Preoperative photographs must document the individuals name; The medical records document that the panniculus or fold causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy (including appropriate prescription medications) over a period of three (3) months. These guidelines are the proprietary information of Highmark. Photographs must include one view of the individual in primary position, one view looking up and one looking down and demonstrate the following: Photographs of the individual looking straight ahead must demonstrate: The eyelid at or below the upper edge of the pupil; The MRD of 2.0 mm or less with the eyes in a straight gaze; Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes; Photographs show the eyebrow below the supra-orbital rim; Photographs should show the excess skin above the eye resting on the eyelashes; Photographs should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape. xc```f``f`a`9 B@1V 0@) Canthopexy may be considered medically necessary when performed for anyONE of the following conditions: Canthopexy is considered cosmetic and, therefore, non-covered when the above medical necessity is not met. Highmark Health reports $22 billion in revenue and $440 million in earnings through year-end 2021. You can file a grievance in person or by mail, fax, or email. considered medically necessary when. xc```b``Ab@(pu VA9N-u`@Hj@2b1 ?)+O`xUO%f$xy|f&
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in each breast is above the 22nd percentile as referenced on the Schnur
Even when you're not sick, we'll help with your wellness goals. an attempt to restore the ability to breast feed. pain not related to other causes such as arthritis, poor posture, acute
s:hj+xr/d r9H4TR5,UuGY_?0h;vcIs2Y;Ib:f2z$ikN,\H%i,oHi|ZuE*{%HZKJG(O!czaw'#ML4#5L;M4&7Ot)2z(6|W4hl2^ %r`T~blr~Y MK=:rrYl3Q/;QTE0K PCP Ph Number Effective Date Specialist Visit Emergency Room $ BS Plan RxGrp RxBlN Cov Eff Date 070/570 HMRKOOI 610014 XX/XX/XXXX IIGHMARK Delaware www.
Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, Cosmetic Surgery vs. Reconstructive Surgery. Y0037_22_4444_M. Reduction
are met: Rhinoplasty
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Reconstructive surgery is performed to improve or restore functional impairment or to alleviate pain and physical discomfort resulting from a condition, disease, illness, or congenital birth defect. Enroll Enroll in Medicare dropdown expander Enroll in Medicare dropdown expander . Addiction and Substance Use Disorder Resource Center. New Dates Added! Rosacea Treatmentany non-pharmacological treatment method, including
picture_as_pdf ICD-10-CM Official Guidelines and Reporting Excludes Notes Policy. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2305824567. Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association . Medical Policy In this section Page A summary of Highmark Blue Shield medical policy guidelines 15.1 Medical care 15.1 ! Therefore, mastectomy for gynecomastia is not indicated for these individuals and is considered cosmetic. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. They are intended to reflect Highmark's reimbursement and coverage guidelines. Community Blue Medicare PPO is a Medicare Advantage Preferred-Provider Organization plan that gives you coverage for every need health, prescription drugs, routine dental, vision, hearing, and preventive care. d[1X?*=PQ_?' Presence of corneal or conjunctival staining; Documentation of epiphora and poor closure of the lids; will be considered cosmetic rather than reconstructive when there is not any functional impairment present. Merge onto PA-100 N. Turn Slight Right onto PA-1002. . pharmacologic therapy, specific for the treatment of rosacea, has failed or is
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Community Blue Medicare PPO includes a high value network of select providers, PLUS an enhanced service model to assist in finding . Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2318079557. Medical Policy Frequently Asked Questions. The Medical Policy Department, in collaboration with physician specialists, develop and maintain medical necessity and coverage guidelines for all medical-surgical products for the Commercial and Medicare Advantage lines of business. Last Name *. Box 22492, Pittsburgh, PA 15222, Phone:1-866-286-8295, TTY: 711, Fax:412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. Mammoplasty,
Photographs must include one view looking up and one looking down and demonstrate the functional deficit; Documented uncontrolled tearing or irritation; Conservative treatments tried and failed. criteria are met: The appropriate amounts
Correction
. These guidelines are the proprietary information of Highmark. Highmark Member Site - Welcome. Requests for an individual under
Reduction mammoplasty
When post-traumatic (i.e., accident) nasal deformity exists; When functional breathing impairment is present. HISTORY Highmark Reimbursement Policy Bulletin Bulletin Number: RP-021 Subject: Annual Gynecological and Rectal Exams Effective Date: January 29, 2018 End Date: Issue Date: January 10, 2022 Revised Date: January 2022 Date Reviewed: December 2021 Source: Reimbursement Policy PURPOSE: Digital rectal exam (DRE) is a routine exam in which a physician inserts a lubricated, gloved finger into The SBC makes it easier for you to understand your health care benefits, find out what's covered, and compare various plans. 905 0 obj
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These technologies may include drugs, devices, procedures and/or gene therapy. This is critical for For questions regarding Coronavirus policy coverage and for testing location information please call 1-8332279377, Monday through Friday, 8 a.m. - 6 p.m. For any [] when there is documented functional impairment: Refer to Medical Policy G-20,Actinic Keratosis, for additional information. non-covered when the above medical necessity is not met. Speak to a Medicare Advisor To speak with a Medicare Advisor, please call: 1-844-593-0265 Request a Call Have a Highmark Medicare Advisor call you to answer your specific Medicare questions, provide an expert evaluation of your current situation and advise you on selecting the right plan. Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. Sliding Scale based on the individuals body surface area (BSA). but not limited to: laser and light therapy [e.g., intense pulsed light (IPL),
Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. Abdominoplasty and/or panniculectomy are considered cosmetic and, therefore, non-covered for all other indications. Suitcase logo - Indicates a member of the BlueCard program. To ensure reimbursement to the correct payee, the group NPI must be included on every claim. 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. The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 2022 Highmark Health Options. exists as a result of a disease state (e.g., facial paralysis). When ALL of the following criteria are met: Blepharoplasty, Lower Lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to anyONE of the following conditions: NOTE: When the physician has determined that theindividualrequires a bilateral blepharoplasty, bilateral blepharoptosis repair or a bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service. Emergency medical and accident services 15.2 ! CareerBuilder TIP. Highmark Health Options is an independent licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield Plans. picture_as_pdf Behavioral Health Coverage for Members Under Age 18. picture_as_pdf Federally Qualified Health Centers Claims (FQHC) Processing Guidelines. Hi, thanks for visiting. Blepharoplasty, Brow lift, AND Blepharoptosis may be considered medically necessary for ANY of the following conditions: AND
However, severe psychological impairment, appropriately documented, can be classified as significant functional impairment on an individual consideration basis. CareerBuilder TIP. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. ; Clinical,
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Discrimination is Against the Law If you do not have an account, no worries, just enter these 2 items below. Licensed Product Name . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 1099 Misc For Central, Eastern, and Western Region Providers: If you have any questions about form 1099-Misc issues, please call 1-866-425-8275. Got a Question? Scar
Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County.
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