Our Quality Standards for Highmark
Striving to do Better, Every Day
Your health is important to us. We work hard to make sure you can get great care when you need it. We do this by:
Learn More About Quality Management
Have questions about the Quality Management program? Call us. We can talk to you about:
We can also send you information on our Quality Management program.
Call 866-231-0847 (TTY 711).
Appeals
You have the right to ask for an appeal if you don’t agree with our decision to deny or reduce a service. An appeal is when you ask us to look again at the care we denied to make sure we made the right decision.
Learn more about your appeal rights:
Care and Disease Management
Helping You Manage All The Moving Pieces
Healthcare can be overwhelming. Our case managers can help make it easier. Your providers know how to help you with your care. It really helps if you know how to care for yourself, too. That’s what our case managers do.
As a Highmark member, we offer many different types of services. Your case manager works with you and your provider to set up a plan of care. You may already be working with a case manager and know how to contact them.
If you think you need case management services or need help contacting your case manager, call us at 866-231-0847 (TTY 711).
Our case managers may also call if:
Your case manager can also help with:
If we call you, a nurse or social worker will:
Utilization Management
How we Make Choices on Care and Services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care.
- Stop certain people from getting services.
- Reward doctors for limiting or denying care.
Getting in Touch With Our Utilization Management Staff
Some Highmark services and benefits need prior approval. This means your provider must ask Highmark to approve the services they want you to have. Services that don’t need approval are:
Our Utilization Review team looks at approval requests. The team decides if:
What should you do if Highmark won’t approve care you think you need? You or your provider can ask us to take another look. We’ll let you and your provider know when we get your request. You can ask us to take another look at services that:
- Are not approved.
- Have been limited in the amount or length of time from what was requested.
Do you have questions about an approval or a denial you got? Call Member Services at 866-231-0847 (TTY 711). Our Utilization Review team or your case manager can help answer your questions.
Your opinion matters!
Every year, we survey our members about the benefits we offer. If you get a survey in the mail, by email or phone, please complete it. Help us make your plan better.
New Technology in Medicine and Care
To make sure we are always using the latest medical treatment and equipment to help you feel your best, our medical director and providers look at all the latest medical changes. They look at:
They also look at the most up-to-date medical and scientific writings. With all this data, they consider:
This work is done to help us decide if a new treatment or care should be added to your benefits.
You Have Rights and Responsibilities
As a Highmark member, you have rights and responsibilities. They are listed in your member handbook. Do you need a printed copy of your member handbook?
Call Member Services at 866-231-0847 (TTY 711)
Your Benefits and How to Get Medical Care
Are you looking to learn more about our services and benefits? Grab your member handbook! You can read about:
Behavioral Health (Mental Health and Substance Use Disorder Services)
Sometimes, dealing with all of the tasks of a home and family can lead to stress. Stress can lead to depression and anxiety. It can also lead to marriage, family and/or parenting problems. Stress can also lead to alcohol and drug use.
If you or a family member is having these kinds of problems, you can get help. Call Highmark Member Services at 866-231-0847 (TTY 711). You can also get the name of a behavioral health specialist who will see you if you need one.
Your benefits include many medically needed services, such as:
You don’t need a referral from your primary care provider (PCP) to get these services or to see a behavioral health specialist in your plan.
If you think a behavioral health specialist does not meet your needs, talk to your PCP. They can help you find a different kind of specialist.
There are some treatments and services your PCP or behavioral health specialist must ask Highmark to approve before you can get them. Your doctor will be able to tell you what they are.
If you have questions about referrals and when you need one, contact Member Services at 866-231-0847 (TTY 711).
Our Notice of Privacy Practices
The notice tells you about how we may use and share your health data. It also tells you how to get this data. The notice follows the Privacy Rule set by the Health Insurance Portability and Accountability Act (HIPAA). View the Notice of Privacy Practices or find it in your member handbook.
Call Member Services at 866-231-0847 (TTY 711) if you want a copy of the Notice of Privacy Practices mailed to you.
Not a Kid Anymore?
It may be time for a new PCP or behavioral health provider
It’s important for you to get the right care from your providers. As an adult, you can choose to change from a provider who specializes in care for children or teens to a provider who focuses on treating adults. This includes providers for physical and behavioral health. We can help if you want to change. We can also help you transfer your medical records.
Start by asking your current PCP or behavioral health provider for a recommendation for a new adult PCP or behavioral health provider. We’re here to help, too. You can change your PCP or behavioral health provider at any time. It’s easy with our Change Your PCP tool. Or call Member Services at 866-231-0847 (TTY 711).