Get care for your physical and mental well-being, including prescription drug coveragefrom the doctors, hospitals, and pharmacies you need. Language Assistance. 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. considered medically necessary whenALLof the following Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. 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. Enroll Enroll in Medicare dropdown expander Enroll in Medicare dropdown expander . Photographs must include the individuals name. sensitive nature of performing procedure on the developing breast; Average weight of tissue planned to be removed If you need these services, contact the Civil Rights Coordinator. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. U.S. Department of Health and Human Services Learn more. endstream endobj Port Wine Stain Treatment may be considered medically necessary for port wine Please use Chrome or Edge or contact our Licensed Medicare Advisors @ 844-593-0265 Claims and Payment Policies. If blepharoplasty, blepharoptosis repair, and brow ptosis repair are requested together, three sets of photographs may be necessary; An automated visual field study was done except for upper eyelid dermatitis, ocular prosthesis problem, and entropian and results interpreted by the provider for the following functional deficits: Visual impairment due to dermatochalasis when the upper eyelid margin is within 2.0 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than or equal to 2.0 mm), with individual in primary gaze; A statement is submitted from the provider regarding the visual field study with documentation of taped and untaped automated visual field testing confirming that the visual deficit shown by the study is caused by the eyelid's condition and that the proposed surgery is being performed in an attempt to correct the visual deficit. of breast tissue outlined above, is considered not medically necessary. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. CareerBuilder TIP. Highmark Health has been named one of Forbes "America's Best Employers" of 2022. You can also e-mail [email protected]. Highmark Health Options is an independent licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield Plans. Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. (If you are not NaviNet enabled, please contact your Provider Relations representative to learn about the benefits of conducting business electronically with Highmark.) Highmark is a registered mark of Highmark, Inc. 2018 Highmark Inc., All Rights Reserved indication. Abdominoplasty, Panniculectomy (Tummy Tuck), may be considered medically necessary when, Preoperative photographs document that the panniculus or fold hangs at or below the level of the. They are intended to reflect Highmark's reimbursement and coverage guidelines. Medicare Highmark Medicare dropdown expander Highmark Medicare dropdown expander. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. These guidelines are the proprietary information of Highmark. . 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. considered cosmetic and, cryotherapy) performed solely for the treatment of post-acne scarring, Suction assisted lipectomy done solely for cosmetic purposes, Temporary hair removal (e.g., waxing, laser). Charges for implantable breast prosthesis are eligible when the implant is provided in conjunction with a reconstructive augmentation mammoplasty. Licensed Product Name . In cases involving psychiatric disorder or involutional changes due to aging, the claim should be accompanied by a report from a psychiatrist who indicates a definite psychiatric condition relevant to the condition to be corrected by the surgery and that the proposed correction is likely to be of significant help in treating the psychiatric problem. Mastectomy for gynecomastia is considered reconstructive when ALL of the following criteria are met: If the above criteria are not met, services may be considered medically necessary when it is documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue. 904 0 obj <> endobj 906 0 obj <>stream other indication. 10/3/2022. When post-traumatic (i.e., accident) nasal deformity exists; When functional breathing impairment is present. Hours of operation are 8:00 a.m. to 4:30 p.m. EST. %PDF-1.7 % Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. Cryotherapy performed for the treatment of active acne is considered cosmetic and, therefore, non-covered. Highmark Health Options medical policies explain the medical services we may or may not cover. POLICY SUMMARY. (in grams) of breast tissue must be anticipated for removal from, If preferred, there are They are used to administer all Highmark medical-surgical products and various fee schedule products. For plans purchased on the Health Insurance Marketplace please call 1-888-510-1084 . Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Rosacea Get the Highmark Plan App. Reduction mammoplasty Reporting Fraud Do not use this mailing address or form to report fraud. Medical Policy Frequently Asked Questions (FAQs). (in grams) of breast tissue must be anticipated for removal from AT LEAST 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. may be considered medically necessary when functional impairment CareerBuilder TIP. 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. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2305824567. 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. 10/13/2022. 1-800-368-1019,800-537-7697(TDD) If there are no procedure specific guidelines associated with a Hair Transplant may be considered medically necessary when performed as a result of injury or burn. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. A claim without valid, legible information in all mandatory categories is subject to rejection or denial. Reduction Refer to the Provider Manual for additional Claims information. 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 [] Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. Mammoplasty, 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. Highmark Member Site - Welcome. stains on the face and neck. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. Dermabrasion may be considered medically necessary when correcting defects resulting from an accident or when functional impairment exists. Room 509F, HHH Building The mission of the Medical Policy Department is to develop and maintain evidence-based coverage guidelines and monitor/assess the medical technology* pipeline to anticipate and plan for the evolution of therapies to ensure appropriate benefit adjudication, patient safety and optimized therapy for our customers. Hair transplant is considered cosmetic and, therefore, non-covered for any other indication. Highmark Choice Company, Highmark Senior Health Company, Highmark BCBSD Inc. and Highmark Senior Solutions Company are Medicare Advantage plans with a Medicare contract. These guidelines address medical services, including diagnostic and therapeutic procedures, injectable drugs, and durable medical equipment. one (1) breast, which is based on the individual's total BSA in Paper claim forms must be submitted on original red claim forms. Learn more. greater than or equal to 18 years of age. pharmacologic therapy, specific for the treatment of rosacea, has failed or is Y0037_19_1662_M Accepted Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2304326090. Ectropion, entropion, or epiblepharon repair for corneal and/ or conjunctival injury; Disease due to ectropion, entropion, trichiasis, or epiblepharon; Poor eyelid tone (with or without entropion) that causes lid retraction and/or exposure; Keratoconjunctivitis often resulting in epiphora; Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to conservative medical management; The impairment is required to be documented by preoperative photographs that must be available upon request. These technologies may include drugs, devices, procedures and/or gene therapy. Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met. Coverage for services may vary for individual members, based on the terms of the benefit contract. therefore, non-covered for any other indication, Otoplasty may be considered medically necessary when performed to improve hearing impairment, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect. Input your Medical Policy search words. Appropriate picture_as_pdf Behavioral Health Coverage for Members Under Age 18. picture_as_pdf Federally Qualified Health Centers Claims (FQHC) Processing Guidelines. The policy bulletins on this web site were developed to assist Highmark Blue Cross Blue Shield in administering standard plan benefits and do not constitute a description of plan benefits. Take the PA-100 N. exit-exit number 14B-towards Fogelsville. see the table attachment at the end of the policy for the Schnur Table. These guidelines are the proprietary information of Highmark. 905 0 obj <>/Metadata 62 0 R/ViewerPreferences 953 0 R/Outlines 215 0 R/OCProperties<><><><><><> 956 0 R 960 0 R 964 0 R]/ON 955 0 R>>/OCGs[ 128 0 R 107 0 R 94 0 R]>>/AcroForm 954 0 R>> endobj 907 0 obj <>/Font<>/XObject<>>>/MediaBox[0 0 612 792]/Contents 908 0 R/Group<>/Tabs/S/StructParents 0/Annots 920 0 R/CropBox[ 0 0 612 792]/Rotate 0>> endobj 908 0 obj <>stream They are intended to reflect Highmark's reimbursement and coverage guidelines. Pre-Approvals Not Required for Authorizations Submitted Between 8/22 - 10/3*. Even when you're not sick, we'll help with your wellness goals. 200 Independence Avenue, SW appropriate support bra; Candidates for breast reduction must be 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 Call 1-877-298-3918. Evaluation and management services 15.1 ! The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator. 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. Requests for an individual under We review our existing medical policies to reflect scientific-based evidence and the current standard-of-care. may be considered medically necessary when ANY of the following criteria It looks like your internet browser doesn't allow our content to display properly. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2319543749. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. These guidelines are the proprietary information of Highmark. 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. Normal range or no hearing loss = 0dB to 20dB.). Reduction/Breast Reductionmay be Procedure codes and diagnosis codes applied to each policy are integrated into the claims processing system which ensures accurate administration of member benefits. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. endstream endobj 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). requires 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. but not limited to: laser and light therapy [e.g., intense pulsed light (IPL), If you suspect fraud, contact Highmark's Financial Investigations and Provider Review (FIPR) Department. Community Blue Medicare PPO includes a high value network of select providers, PLUS an enhanced service model to assist in finding . Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. QhrfF}B}ausF$jCN9k.WdjzhJa//jc6-y$=jf2jZox"dj88Ii N,A\LsYAd>F!g$ If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at 1-800-876-7639 or TTY at #711 to receive assistance free of charge. Discrimination is Against the Law j#pYA|G-&^2@!SHT)x;c>\T-WnSCX- +k#&"}/wQWY\CO|/L%CP 0.V#;#:6%F nP`%.YX[~9+0l; ,e%j4B/_2="T^ZyIVS(_zJ.R'BOa+MUTi13[H~)`:$P1"psj# .nZ-yebnBFQBK/Z9b / ^R, d5e [vU4>|9*. 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