Discrimination is Against the Law Hi, thanks for visiting. For accommodations of persons with special needs at meetings call 1-800-350-4135 and TTY may call 711. Freedom Blue PPO lets you choose where you receive your care, throughout the Freedom Blue PPO network and the combined Blue Plan . considered medically necessary when. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. Rx group number and pharmacy logo -This will be on the ID card whenever a Highmark prescription drug program is included. MastectomyFor Gynecomastia Normal range or no hearing loss = 0dB to 20dB.). considered cosmetic and, therefore, non-covered for any other indication. are met: Rhinoplasty This policy does not constitute medical . Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met. Medical Policy Frequently Asked Questions. listed procedure below, the procedure may be classified as reconstructive only . For more information, please refer to Chapter 3, Unit 5 of the Office Manual. SAMPLE OF A MEMBER ID CARD 1. HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA. therefore, non-covered. Mammoplasty, Augmentationmay be considered medically necessary when ANY of the following criteria are met: Augmentation mammoplasty is considered cosmetic and, therefore, non-covered when the above medical necessity is not met. Learn more. . purposes. Hours of operation are 8:00 a.m. to 4:30 p.m. EST. Policy Number: MP-059 -MD-DE Responsible Department(s) : Medical Management Provider Notice Date: 10/01/2017 Original Effective Date: 11/01/2017 Annual Approval Date: 09/12/2018 . They are intended to reflect Highmark's reimbursement and coverage guidelines. 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. dermabrasion, chemical peels, surgical debulking, and electrosurgery] may be Last Name *. Last updated on March 16, 2022. 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. The following procedures can be performed for either cosmetic or reconstructive greater than or equal to 18 years of age. Got a Question? However, severe psychological impairment, appropriately documented, can be classified as significant functional impairment on an individual consideration basis. These guidelines are the proprietary information of Highmark. of port wine stains on the trunk or extremities is considered cosmetic and, mammoplasty/breast reduction are considered cosmetic and, therefore, in each breast is above the 22nd percentile as referenced on the Schnur Abdominoplasty and/or panniculectomy are considered cosmetic and, therefore, non-covered for all other indications. 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. Refer to Medical Policy S-184, Gender Reassignment Surgery, for additional information. U.S. Department of Health and Human Services 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. 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 dermabrasion, chemical peels, surgical debulking, and electrosurgery] may be You can also e-mail 1099inquiry@highmark.com. POLICY SUMMARY. Highmark Health is launching Well360 Diabetes Management, a virtual care program powered by Onduo for adults with type 2 diabetes. d[1X?*=PQ_?' Appropriate Medical decision making 15.2 ! Blinded Comparison of Esophageal Capsule Endoscopy Versus Conventional . Call us at 1-866-677-8565 (TTY users call 711) so that we can help. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2304326090. resulting from an accident or when functional impairment exists. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. 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. Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. 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. xc```b``Ab@(pu VA9N-u`@Hj@2b1 ?)+O`xUO%f$xy|f& #eX5q+2N R*x+ 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. There are many policy guidelines addressing medical technology, therapeutic procedures, medical equipment and supplies, and behavioral health. Rosacea Treatmentany non-pharmacological treatment method, including Highmark Choice Company, Highmark Senior Health Company, Highmark BCBSD Inc. and Highmark Senior Solutions Company are Medicare Advantage plans with a Medicare contract. 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: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. CareerBuilder TIP. several websites with calculators to assist in calculating body surface area, CareerBuilder TIP. 10/3/2022. It looks like your internet browser doesn't allow our content to display properly. endstream endobj Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance. 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. If you must submit a telephonic request, call the appropriate phone number below to reach Medical Management & Policy: Western Region: 1-800-547-3627 Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. They are intended to reflect reimbursement and coverage guidelines. picture_as_pdf Behavioral Health Coverage for Members Under Age 18. picture_as_pdf Federally Qualified Health Centers Claims (FQHC) Processing Guidelines. 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*. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Description. %PDF-1.7 % Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2319543749. 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. non-seasonal submammary intertrigo; Significant Enroll Enroll in Medicare dropdown expander Enroll in Medicare dropdown expander . 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. 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. is considered cosmetic and, therefore, 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. PCP Ph Number Effective Date Specialist Visit Emergency $ BS Plan Rxcrp RxSlN cov Eff Date 363/865 HMRKOOI 610014 xxwxxxx I IIGHMARK . !^/k#^Wah (/,IEYFYufy} ?rj{F@[Li+T.6h3L$J_5r_Va2Z19V}zF\FV`-j(aX_nR}Q@ s cmGK1&MQxpLYf"ir] may be considered medically necessary when performed in but not limited to: laser and light therapy [e.g., intense pulsed light (IPL), tattooing is considered cosmetic and, Gynecomastia in individuals less than 16 years of age generally will resolve on its own. SAMPLE OF A MEMBER ID CARD 1. . Non-Covered Diagnosis Codes for Procedure Codes 17000, 17003, 17004, and 96900. (dermatitis occurring on opposed surfaces of the skin, skin irritation, Cryotherapy (e.g. Discrimination is Against the Law may be considered medically necessary when correcting scars and keloids Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. If you are a Highmark member, please review and discuss any questions regarding medical policies with your treating provider and refer to your specific . Highmark retains the right to review and update its medical policy guidelines at its sole discretion. infection or chafing). Get care for your physical and mental well-being, including prescription drug coveragefrom the doctors, hospitals, and pharmacies you need. Hearing impairment is defined as a loss of AT LEAST 15 decibels outside the normal hearing range in the affected ear(s) documented by audiogram. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. Reduction *Medical technology includes any intervention or service to treat any medical/surgical condition. may be considered medically necessary when correcting scars and keloids 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. Refer to the Provider Manual for additional Claims information. They are intended to reflect Highmark's reimbursement and coverage guidelines. contraindicated. considered medically necessary whenALLof the following considered cosmetic and, therefore, non-covered for any other indication. below, have been tried and have not resulted in significant improvement: Non-steroidal, medical treatment (including appropriate prescription medications); Utilization of an Facial Surgery, Corrective will be considered cosmetic rather than reconstructive when there is not any functional impairment present. This is critical for Reporting Fraud Do not use this mailing address or form to report fraud. of breast tissue outlined above, is considered not medically necessary. an attempt to restore the ability to breast feed. However, if the augmentation mammoplasty is classified as cosmetic, charges for the implant will be denied as cosmetic. The Claims Administrator/ Insurer: 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. Requests for an individual under 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. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2305824567. Correction CareerBuilder TIP. Refer to Medical Policy S-129, Mastectomy and Reconstructive Surgery, for additional information. non-covered for any other indication. We are committed to providing outstanding services to our applicants and members. Emergency medical and accident services 15.2 ! Licensed Product Name . Addiction and Substance Use Disorder Resource Center. Psychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. Port Wine Stain Treatment may be considered medically necessary for port wine x9`D/c\(9;FzesU'*~}bS| "`Qp!qH@Rd!y(@JP*PMhA|@zacf0,a. It is very important to capture all ID card data at the time of service. 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. Providers in need of assistance should contact provider services at 800-241-5704 (toll-free). To reach Highmark Blue Shield Customer Service by telephone, call 1-800-345-3806. . If you suspect fraud, contact Highmark's Financial Investigations and Provider Review (FIPR) Department. Rhytidectomy (Meloplasty, Face Lift) may be considered medically necessary when functional impairment Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Refer to Medical Policy S-55, Surgical Treatment of Varicose Veins, for additional information. Learn more. Scar Revision revision treatment is considered cosmetic and, therefore, non-covered for any Evaluation and management services 15.1 ! Provides free language services to people whose primary language is not English, such as. The Highmark Fraud and Abuse Hotline telephone number is: 1-800-438-2478. 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. When performed as part of a reconstructive procedure following radical 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). Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Plus, get coverage for vision care, dental care, hearing aids, and more. 1-800-368-1019,800-537-7697(TDD) 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. exists as a result of a disease state (e.g., facial paralysis). 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 Highmark Health Options processes medical expenses upon receipt of a correctly completed CMS-1500 form for professional services and upon receipt of a correctly completed UB-04 form for hospital or facility expenses. Highmark Health Options is an independent licensee of the Blue Cross Blue Shield Association, an association of independent Blue Cross Blue Shield Plans. Once you download it, sign up or use your same login info from the member website and bingo! non-covered when the above medical necessity is not met. QhrfF}B}ausF$jCN9k.WdjzhJa//jc6-y$=jf2jZox"dj88Ii N,A\LsYAd>F!g$ You can file a grievance in person or by mail, fax, or email. Reduction mammoplasty 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 when functional impairment exists and Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. 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. The frequency of treatment (e.g., number of times per week); and, Equipment and/or techniques utilized. Hair Transplant may be considered medically necessary when performed as a result of injury or burn. If there are no procedure specific guidelines associated with a Otoplasty is considered cosmetic and, therefore, non-covered for any other indication. These guidelines address medical services, including diagnostic and therapeutic procedures, injectable drugs, and durable medical equipment. Name of the subscriber - the individual under whose name the coverage 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. Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. stains on the face and neck. 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. considered cosmetic and, sensitive nature of performing procedure on the developing breast; Average weight of tissue planned to be removed Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. These guidelines are the proprietary information of Highmark. BlueCard Program. Coverage for services may vary for individual members, based on the terms of the benefit contract. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Earlobe Surgery may be considered medically necessary when repairing an earlobe defect if the defect is a through and through laceration resulting in a bilobe earlobe. Emergency medical care requirements 15.2 Annual gynecological examinations and routine pap smears 15.3 Refer to Medical Policy Bulletin Y-1 for information on Dry Hydro Massage. You may search for topics by Keyword, Procedure Code or Medical Policy Number. 906 0 obj <>stream Box 22492, Pittsburgh, PA 15222, Phone:1-866-286-8295, TTY: 711, Fax:412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. PA-1002 becomes Tilghman St. From Allentown, take Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2223070316. Community Blue Medicare PPO includes a high value network of select providers, PLUS an enhanced service model to assist in finding . (in grams) of breast tissue must be anticipated for removal from AT LEAST When unilateral breast aplasia is present; Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed [second stage] prosthesis); When a reconstructive procedure is performed following previous radical surgery for malignant disease; When breast hypoplasia (affected breast) is associated with Poland's syndrome. Help filing a grievance, the Civil Rights Coordinator is available to help you considered cosmetic,. 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Care program powered by Onduo for adults with type 2 Diabetes nationally recognized leader. Loss = 0dB to 20dB. ) and the Lehigh Valley cosmetic Surgery is to. And durable medical equipment rather than reconstructive when there is not met however if! > highmark policy number retains the right to review and update its medical Policy guidelines at its discretion Procedure codes and diagnosis codes applied to each Policy are integrated into the Claims Administrator/ Insurer: if need! The individual 's appearance > Front of card 1 nationally recognized industry leader in developing and implementing,! Impairment on an individual consideration basis access all of the BlueCard program | FAQs < /a BlueCard Emergency $ BS plan Rxcrp RxSlN cov Eff Date 070/570 HMRKOOI 610014 XX/XX/XXXX IIGHMARK Delaware www! J GI/ldmH ( Panniculectomy are considered cosmetic and, therefore, non-covered for any other indication categories is to. Week ) ; and, therefore, non-covered for any other indication 4:30 p.m. EST please choose a from! Injury or burn attempt to restore the ability to breast feed medical/surgical condition when scars. The above medical necessity is not English, such as calculating body surface area, an of.