Provider Resource Center

[{"id":434,"versionId":5,"title":"Clinical Services Referral Guide","type":4,"subType":null,"childSubType":"","date":"6/10/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eHighmark Wholecare has developed a robust offering of clinical programs that offer whole person care to our members and improve health outcomes. We are excited to share that the updated \u003ca href=\"https://content.highmarkprc.com/Files/Wholecare/Forms/ClinicalServicesReferralGuide.pdf\"\u003e2024 Clinical Services Referral Guide\u003c/a\u003e\u0026nbsp;is now available for providers to review the programs accessible to their Highmark Wholecare patients.\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":392,"versionId":5,"title":"UM Transitions","type":4,"subType":null,"childSubType":"","date":"3/26/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003eImportant UM Authorization Updates:\u003c/strong\u003e\u0026nbsp;Effective May 1st, there\u0026nbsp;are updates to the authorization requirements and processes for various Highmark Wholecare services. To learn more about these specific changes and to review reference materials, visit the following links:\u003cstrong\u003e \u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/391/New-Authorization-Requirements-for-Musculoskeletal-Pain-Management-Diagnostic-Imaging-and-Physical-Medicine\"\u003eMusculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/390/New-Authorization-Process-for-Family-Planning\"\u003eFamily Planning\u003c/a\u003e;\u0026nbsp;\u003c/u\u003e\u0026nbsp;\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/389/New-Authorization-Requirements-for-Cardiology\"\u003eCardiology\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":356,"versionId":5,"title":"Prior Authorization Updates","type":4,"subType":null,"childSubType":"","date":"2/12/2024","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003e\u003cstrong\u003e\u003cspan\u003eEffective 7/1:\u003c/span\u003e\u003c/strong\u003e\u003cspan\u003eServices requiring prior authorization from Highmark Wholecare\u0027s UM Department must be submitted through the GuidingCare portal in Navinet. If the portal is unavailable, you can call our UM team at 1-800-392-1147 TTY: 711 or fax the request using \u003cstrong\u003e\u003cu\u003e\u003ca href=\"https://wholecare.highmarkprc.com/Provider-Newsletters/Wholecare-Newsfeed/378/UM-Fax-Number-Changes\"\u003eUM fax numbers\u003c/a\u003e\u003c/u\u003e\u003c/strong\u003e. Shift care providers and services requiring authorization through HealthHelp \u0026amp; OncoHealth will continue to follow the current process.\u003c/span\u003e\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2},{"id":289,"versionId":5,"title":"E-Subscribe Provider Website Banner","type":4,"subType":null,"childSubType":"","date":"12/6/2023","endDate":null,"additionalDate":null,"imageUrl":null,"url":null,"baseUrl":null,"urlText":null,"description":"\u003cp\u003eThe Highmark Wholecare Provider Newsletter has been replaced with the \u003cstrong\u003e\u003cem\u003eProvider News\u003c/em\u003e monthly email\u003c/strong\u003e. The \u003cem\u003eProvider News\u003c/em\u003e email will become our primary communications channel, allowing us to consolidate and simplify updates for you each month. \u003ca href=\"https://wholecare.highmarkprc.com/e-Subscribe-for-Publications-and-Notifications\"\u003eSubscribe here\u003c/a\u003e to stay up-to-date with Highmark Wholecare member programs, provider policies, claims, reimbursement, and more!\u003c/p\u003e","longDescription":null,"visible":false,"archive":false,"liveStatus":2}]

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8/20/2024

CMS Requirements and Credentialing for Psychological Services

According to CMS policy, a person must be licensed by the state where practicing to perform psychological services. Additionally, the individual’s training and scope of practice must allow that person to perform such services. These training and license requirements are intended to ensure an adequate level of expertise in the cognitive skills required to perform diagnostic and therapeutic psychological services. Additionally, these requirements help ensure patients receive the best possible care.

Under the “incident-to” provision, individuals who are not licensed, or otherwise authorized by state law to provide psychological services, may not provide these services. This level of professional credentialing is necessary to furnish appropriate medically necessary psychological services. The description below details who can perform services under the “incident-to” provision.

What is “Incident-to”?

“Incident-to" a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. Coverage of services and supplies “incident-to” the professional services of a physician in a private practice is limited to situations in which there is general physician supervision of auxiliary personnel. To be considered an employee (auxiliary personnel), the nonphysician performing an “incident-to” service is defined as any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician or legal entity that employs or contracts with the physician.

References:

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The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

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