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Provider and Facility Reference Manual

Section 1 - About Blue Shield

Highmark Blue Shield of Northeastern New York is one of many individual BlueCross and Blue Shield Plans in the United States. In addition to our Albany-based Plan, our parent company, HealthNow New York Inc., operates two other divisions:

  • Highmark Blue Cross Blue Shield of Western New York, based in Buffalo, NY
  • HealthNow Administrative Services (HNAS), located in Blue Bell, PA

For the convenience of our participating Highmark Blue Shield of Northeastern New York providers, we have developed this manual, which includes all the information you will need regarding:

  • The health care products we offer
  • The services we provide to physicians and members
  • Our policies and procedures
  • Claims information
  • Provider reimbursement

There will be periodic updates to this manual. We hope you will find this manual to be a helpful reference tool.

Vision and Mission Statements

Blue Shield is committed to working with our participating physicians to ensure members receive quality, cost-effective health care services. To this end, we have adopted the following vision and mission statements:

Our Vision: To be the preferred health care plan for our communities.

Our Mission: To develop and provide innovative and cost-effective health care delivery solutions to support the needs of our members, stakeholders, and communities.

Blue Shield offers a wide variety of managed care and traditional products to groups and individuals. We are dedicated to providing members with quality health care that is cost-effective and easy to access.

Quality Management

Blue Shield's Quality Management programs are designed to ensure that members have access to the care and services they need with the ultimate goal of improving the health care and services provided to our members. Blue Shield's efforts to provide quality care to our managed care members have been recognized by accreditation through the National Committee for Quality Assurance (NCQA), a non-profit organization that has established an accreditation system to evaluate health plans across the nation.

Access to Care

To ensure members have appropriate access to care, we contract with hospitals and physicians in our operating area. Physicians who participate with our managed care programs are required to be available 24 hours per day, seven days per week. If the physician is unavailable, he or she is responsible for making on-call coverage arrangements with other participating physicians.

Blue Shield has taken steps to reduce hospital and medical expenses without compromising access to or quality of care. A few of these initiatives are listed here. Complete details about these and other Utilization Management initiatives can be found in this manual.

  • Our Utilization Management Department streamlines the preauthorization and facility review functions into one unit. This provides better service and a more personal touch for our physicians.
  • Our Case and Disease Management Department follows a member-focused program that facilitates a plan of care that is developed with a physician’s orders.
  • Patient-Centered Medical Home (PCMH) is a voluntary program for primary care physicians (adult and pediatric) that recognizes high-performing practices in key areas of clinical quality and care coordination. PCMH is sponsored by the National Committee for Quality Assurance (NCQA) – a private, not-for-profit organization dedicated to improving our nation’s health care quality.
  • Implementing the use of a managed care prescription drug formulary to improve the value of pharmaceutical care delivered through proper consideration of both quality of care and economic issues.

Our Access to Care policy for physician appointments is established for PCP, Behavioral Health and OB-GYN care to ensure Blue Shield members timely accessibility to health and behavioral care services. Practitioners are required to follow the Access to Care policy available on our provider website.

The Physician's Role in Managed Care: The Primary Care Physician

Managed care members are required to select a primary care physician (PCP) from our directory of participating providers. The PCP is responsible for monitoring his or her patients and coordinating the delivery of all health care services, including preventive and routine medical care, hospitalization, and specialized care within the network. Members are instructed to contact their PCP before seeking medical treatment, except in the case of a life threatening medical emergency. This gives the PCP an opportunity to provide the member with the care he or she needs in the most appropriate manner.

The Physician's Role in Managed Care: The Specialist

The specialist is responsible for providing care as coordinated by the member's PCP. At each visit, it is necessary for the specialist's office to verify the member's coverage and to be aware of any referral requirements. If a member's coverage indicates that a referral is necessary and it is not in place, you must inform the member prior to services being rendered that he or she will be responsible for payment. Financial responsibility must be established at the time of each visit. Claims that are denied because there is not a valid referral in place, and no patient waiver exists, cannot be billed to the member.

It is the specialist's responsibility to keep the PCP informed about any care the patient may be receiving by promptly reporting the treatment plan or progress notes to the PCP.

OB-GYNs are also considered specialists and the routine OB-GYN services they provide do not require a referral.  All female members have direct access to obstetrical/gynecological care, so they may receive care from their OB-GYN. To help coordinate care, the OB-GYN provider should routinely discuss the treatment plan with the patient's PCP.

For OB-GYN services, the patient pays the PCP copay.

The Physician's Role in Managed Care for Members with Special Needs (Including Medicare Advantage Dual-eligibles)

For planned and unplanned transitions between care settings (a member’s usual care setting to a hospital, or from a hospital to the next setting), the sending provider is expected:

  • To share the care plan with the receiving setting within one business day of notification of the transition.
  • To inform the member (or the member’s responsible party) of the care transition process.
  • To inform the member (or the member’s responsible party) about changes to the member’s health status and plan of care.
  • Federal law bars Medicare providers from collecting Medicare Part A and Medicare Part B deductibles, coinsurance, or copayments from those enrolled in the Qualified Medicare Beneficiaries (QMB) program, a dual eligible program which exempts individuals from Medicare cost-sharing liability. (See Section 1902(n)(3)(B) of the Social Security Act, as modified by 4714 of the Balanced Budget Act of 1997).
  • Balance billing prohibitions may likewise apply to other dual-eligible beneficiaries in Medicare Advantage (MA) plans if the State Medicaid Program holds these individuals harmless for Part A and Part B cost-sharing.
  • Further, Medicare Advantage enrollees cannot be discriminated against in the delivery of health care services, consistent with the benefits covered in their policy, based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, or source of payment.  Discrimination based on “source of payment” means, for example, that MA providers cannot refuse to serve enrollees because they receive assistance with Medicare cost-sharing from a State Medicaid program.

Members who are eligible for both Medicare and Medicaid (dually eligible) may have certain services covered by the Medicaid programs. To find out which benefits are covered by the member’s Medicaid benefit, please call provider service at 1-877-327-1395.

Culturally and Linguistically Appropriate Services

Physicians are requested to provide culturally and linguistically appropriate services to Blue Shield members. Cultural competency in health care professionals results in healthier patients. Some of the most common misunderstandings between doctors and their patients are diagnosis, test results and prescription instructions. Understanding what you say to them about their health can mean the difference between your patients' compliance or non-compliance.

For information about free online training on Culture and Health Literacy with Continuing Education Units (CEUs).

Provider Network Management and Operations and Provider Experience

Our Provider Network Management and Operations and Provider Experience teams are your primary link with Blue Shield. Our commitment to partnering with our participating providers is vital to providing quality coverage for our members. A Provider Network Management Specialist or Practice Account Manager will visit your office to share information and work with you to analyze practice patterns in an effort to help you provide quality, cost-effective care. With a variety of reports and educational material, we can customize information to meet your specific needs.

Our provider website, includes a variety of convenient Blue Shield content such as:

  • Provider and Facility Reference Manual
  • Dental Reference Manual
  • Chiropractic Reference Manual
  • Blue Bulletin news feed (our primary vehicle for communicating important updates and tips to you once a month)

Use your HEALTHeNET login for complete access to both non-secure and secure information in the Provider section of the Blue Shield website. Go to HEALTHeNET to register for a login.

For additional information on the services available to providers, please contact our Provider Relations and Contracting Department at (518) 220-5601.

Provider Service Centers

Our Provider Service Center representatives are trained to assist you with any of the following, and much more:

  • Answers to benefit questions
  • To check on the status of a claim
  • To request an adjustment

You can reach our Provider Service Centers from 8 a.m. - 5 p.m., Monday to Friday. To serve you best, Blue Shield has dedicated service centers for each line of business that we offer. Please refer to the Provider Telephone and Web Reference Guide for our contact information.

Provider Telephone and Website Reference Guide

Provider Service

Managed Care and Traditional/ Indemnity):1-800-444-4552

or (518) 220-5620


Government Programs: 1-877-327-1395

Provider Enrollment 1-800-666-4627
Provider Network Management and Operations (518) 220-5601
Provider Website