Highmark WV Update
Highmark Foundation is pleased to announce a Lunch and Learn on HPV (human papillomavirus). Please join us on
December 4, 2017 to learn about HPV, reducing barriers to immunization, eliminating myths, and how to reduce risk of developing this disease.
Dr. Pamela Murray will provide information and answer your questions about HPV, treatment options, and prevention efforts. The forum is open to those who want to learn the facts about HPV including business and healthcare professionals, school nurses, teachers, parents, and the community. There is no cost to attend and lunch will be provided
Time: 11:30 a.m–1:30 p.m.
Registration begins at 11:30 a.m. Lunch served at noon
Location: Grand Pointe Conference Center 1500 Grand Central Avenue Vienna, WV 26105
RSVP by November 28, 2017, to Tracey Pollard by email:
firstname.lastname@example.org or phone (toll-free):
Highmark’s peer-to-peer review process for prior authorization requests for Medicare Advantage members is no longer available as of Sept. 12, 2017
The peer-to-peer conversation offered providers the opportunity to discuss a pending adverse determination of an authorization request for medications or medical services with another peer designee from Highmark before Highmark made a final decision. Elimination of the Medicare Advantage peer-to-peer review process benefits the member and the provider by resulting in a more timely and efficient processing of authorization requests.
With notification of a denial decision, providers and members continue to be informed of their appeal rights and procedures. The denial letter includes instructions on how a provider or member can request a Medicare Advantage appeal. The appeal will provide an opportunity for review of the initial determination and any additional documentation provided to support the request.
To ensure a thorough initial review of your authorization requests for medications or medical services for your Medicare Advantage patients, please be sure to:
- Submit all relevant medical records and pertinent information to support the request with the initial authorization request to Highmark.
- Respond promptly to any requests for additional information so a comprehensive review and decision can be made efficiently.
: Highmark’s NCQA-accredited vendors (Tivity Health [formerly Healthways], National Imaging Associates, Inc., eviCore healthcare, and naviHealth) will continue to offer the peer-to-peer review process for prior authorization requests for Medicare Advantage members. These vendors must offer the peer-to-peer review process to meet NCQA accreditation requirements. Additionally, the peer-to-peer review process for prior authorization requests continues to be available for Highmark’s commercial product members.
Highmark has also announced that the plan will be making formulary changes as of January 2018. If you are a prescribing physician in our network, effective Jan. 1, 2018, Highmark will be making changes to specific drugs included in the formularies and Pharmacy benefit programs for Medicare Advantage plans. Letters outlining this update,are being mailed to prescribing providers in the near future. We encourage you to be looking for the letters that will arrive shortly.
WV Medicaid Update
Please be aware that as of December 31, 2017, all current MCO providers must be enrolled with WV Medicaid or the MCO will terminate your contract. This means that if you are currently seeing MCO patients and are not seeing fee for service Medicaid, you MUST enroll with WV Medicaid in order to continue participating with the MCOs.
As of January 1, 2018, Molina will begin screening new MCO network providers who must have a participation agreement in effect with the State Medicaid agency, even if they do not plan to participate in the Medicaid FFS program. The Managed Care Federal Rule (March 2016) stated that Medicaid has the ultimate responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers. These MCO providers will also be subject to revalidation.
As of June 1, 2018, Cycle 2 of Provider Revalidations will begin for WV Medicaid providers, which will include MCO providers, as applicable. As a reminder, provider revalidation is require at least every 5 years for provider screening and enrollment. Revalidation date is based on the most recent effective data.
The WV State Medical Association has been made aware that CAMC Health System has communicated they will continue to
accept Unicare in 2018 and continue to treat Unicare MCO beneficiaries.