HIPAA Billing

HIPAA Billing Internal Dispute Process At Highmark

HIPAA billing dispute regarding claims payment decisions made by Highmark can be requested by any provider that treats a Highmark member. Any claim dispute between a provider and Highmark arising from a provider’s request for payment is solely a contract dispute between the provider and Highmark, and does not involve any other party. Accordingly, it is important to note that the dispute must not be made against the plan through which a member receives benefits. This limitation applies to plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) and/or the Patient Protection and Affordable Care Act of 2010 (PPACA).

All Highmark insurance policies for members contain anti-assignment provisions. This means that a provider cannot be a “participant” or “beneficiary” or “receive benefits” (covered services) under the terms of a member’s plan (whether insured or self-insured). Only members are entitled to receive benefits. As a result, a provider cannot dispute a claim with benefit plans or plan sponsors in the event a member’s benefits are denied in whole or in part.

Highmark offers several ways for providers to express dissatisfaction with their claims payment or lack thereof. Network participating providers may:

  • Submit a NaviNet® Claim Investigation Inquiry
  • Call Provider Services
  • Send written correspondence to Customer Service

It is the provider’s responsibility to submit all necessary information about the billing dispute and any additional documentation. If Highmark determines there is incomplete information, the provider will be contacted to provide the necessary information. Once all documentation is received, a billing dispute is routed to the appropriate department for research and review. A service representative will review the applicable claim(s) and determine whether the claim(s) processed correctly. Individual departments within Highmark have varying levels of review and will notify the provider at various stages of the review, as applicable. In certain instances, internal billing dispute processes are considered final. In cases where eligibility requirements are met, further billing dispute resolution processes may be available. No matter the outcome, each provider who submits a billing dispute will receive notification advising them of the outcome and the reason for the decision. Actions will be taken to remedy the billing dispute, if the provider’s contention was correct.

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