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Understanding Highmark Blue Shield Rehab Insurance
Coverage Overview
Highmark Blue Shield provides comprehensive insurance options for addiction treatment services, designed to support individuals seeking rehabilitation. Under the Affordable Care Act (ACA), Highmark's marketplace plans cover various aspects of drug and alcohol rehab programs, which includes treatment for mental and behavioral health disorders. Coverage specifics can vary significantly depending on the specific plan chosen [1].
As an independent licensee of the Blue Cross Blue Shield Association, Highmark serves over 6 million Americans, primarily in Pennsylvania, Delaware, and West Virginia. These plans are categorized by metal levels, indicating the balance between costs and coverage available to policyholders.
Coverage TypeDescriptionMental and Behavioral HealthCoverage includes therapy and counseling for substance abuse and related issues.Inpatient ServicesIncludes costs associated with rehab facilities as mandated by ACA regulations.Outpatient ProgramsCoverage for continuing care and outpatient therapy sessions.
Treatment Options
Highmark Blue Shield offers access to various treatment methods, including in-network medication-assisted treatment (MAT) and therapy options. Individuals can seek both group and individual therapy, in addition to counseling and support for opioid use disorders through available virtual treatment platforms like Bright Heart Health, which operates 24/7 [3].
Treatment options under Highmark plans typically encompass:
For a more detailed understanding of specific coverage limitations and benefits, consult our article on uhc rehab insurance limitations and benefits.
Physical Medicine Coverage
Highmark Blue Shield rehab insurance provides coverage for physical medicine and rehabilitation that is aimed at restoring a patient's lost or reduced level of function due to injury or illness. The specifics of this coverage are determined based on the individual or group customer benefits.
Rehabilitative Therapy
Rehabilitative therapy plays a crucial role in recovery. Under Highmark's guidelines, a typical physical medicine session can last up to one hour and may include up to four physical medicine modalities or procedures performed by the same provider on the same date of service.
Key Points:
Modalities and Procedures
Highmark Blue Shield covers various modalities and procedures as part of physical medicine. These are usually outlined in the patient's treatment plan, which should be documented in the medical record.
Modality/ProcedureDescriptionAquatic TherapyInvolves exercises performed in water, must have a defined treatment plan outlining goals. Should be reported using procedure code 97113. (Highmark)Gait TrainingFocuses on improving walking skills and mobility after an injury. Requires a clear treatment approach.Physical TherapyEncompasses a range of techniques to restore function, must adhere to treatment protocols outlined in individual or group benefits.
Coverage for these modalities and procedures is determined based on member benefits and specific guidelines must be followed to ensure proper billing and reimbursement of services. Providers may bill members for any services that exceed specified benefit limitations. For more details on coverage, consider visiting related articles, such as UHC rehab insurance limitations and benefits or capital blue eligibility for addiction treatment.
Specific Therapy Services
Highmark Blue Shield rehab insurance covers a variety of specific therapy services aimed at improving the patients' functional abilities after injury, illness, or disease. This section reviews the coverage details for habilitative therapy, aquatic therapy, and gait training.
Habilitative Therapy
Habilitative therapy is designed to restore, maintain, or improve functional levels after an injury or illness. These services are covered under Highmark Blue Shield rehab insurance when ordered by a qualified provider and if the member has habilitative benefits. The focus is on enabling patients to achieve specific functional goals that enhance their quality of life, particularly when facing challenges related to developmental or age-related conditions.
CriteriaDetailsCoverageOrdered by a professional provider, requiring habilitative benefitsObjectiveRestore, maintain, or improve functionDocumentationMedical necessity and treatment goals must be clearly defined
For more information on the types of services covered, you may refer to the policy on UHC rehab insurance limitations and benefits.
Aquatic Therapy
Aquatic therapy is eligible for coverage under Highmark rehab insurance when it is conducted with the specific intention of restoring function lost due to injury or illness. It must involve direct patient contact with a therapist, who is responsible for establishing a treatment plan with clear, achievable goals.
CriteriaDetailsCoverageMust have direct patient contact and a detailed treatment planProcedure Code97113FocusRestoring function; not for maintaining current function levels
Providers are required to report aquatic therapy sessions with the appropriate procedure code and maintain documentation of treatment objectives. Further details can be found through references on Anthem coverage for addiction treatment.
Gait Training
Gait training is included in Highmark Blue Shield's rehab insurance and is suited for individuals experiencing balance, vertigo, or similar conditions following certain medical issues. This therapy focuses on improving the patient’s ability to walk and navigate safely and effectively.
CriteriaDetailsCoverageAccepted for specific conditions affecting gait or balanceDocumentationMust be part of an ongoing treatment planFocusImproving gait, balance, and addressing safety in movement
Like other therapies, gait training requires that the treatment be documented within the patient's ongoing care plan. For more insights into eligibility requirements, please refer to the guidelines on eligibility for GHP addiction treatment.
These specific therapy services have unique coverage stipulations that ensure patients receive the appropriate support for their rehabilitation needs.
Rehab Programs and Coverage
When contemplating rehabilitation options, understanding the coverage provided by Highmark Blue Shield is essential. This section delves into the various rehab programs available through Highmark, focusing on inpatient and outpatient options, along with their respective coverage details.
Inpatient Rehab
Inpatient rehab programs covered by Highmark involve intensive treatment at specialized facilities. These programs typically include detoxification, therapy, counseling, and medical supervision. Individuals seeking such treatment should note that some Highmark insurance plans may cover the costs associated with inpatient programs, which often encompass both individual and group therapy, medically assisted detoxification, and related services.
Inpatient Rehab Coverage FeaturesDescriptionDetoxificationMedically supervised withdrawal from substances.Therapy SessionsIncludes individual and group counseling geared towards recovery.Medical SupervisionContinuous medical oversight for safety during intensive therapy.Additional ServicesMay cover related services such as psychiatric evaluations and follow-up care.
It's important for individuals to review their specific Highmark plan to discern which rehabilitation centers are included in their coverage and to understand potential out-of-pocket expenses [2].
Outpatient Rehab
Outpatient rehab programs, also covered by Highmark, allow individuals to receive treatment while continuing their daily lives at home. These programs typically feature therapy sessions, counseling, medication management, and other forms of support, thus offering flexibility that inpatient settings do not provide [5].
Outpatient Rehab Coverage FeaturesDescriptionTherapy SessionsIndividual and group counseling sessions conducted on a schedule.CounselingOngoing support and guidance from qualified professionals.Medication ManagementAssessment and prescription of necessary medications for recovery support.FlexibilityTreatment can occur several times a week or fully from home.
To fully understand the specifics regarding coverage limits and anticipated costs for outpatient treatment, individuals are encouraged to contact Highmark directly or visit their website for more information [2].
By familiarizing themselves with Highmark's coverage for both inpatient and outpatient rehab programs, individuals can make more informed decisions about their treatment options. Always consider reviewing the requirements for Highmark Blue Shield rehab insurance specific to each plan, as coverage limits—including the duration of coverage and number of therapy sessions—can vary significantly.
Highmark Insurance Plans
Highmark Blue Shield offers insurance plans that include coverage for addiction treatment programs. Understanding these plans requires an awareness of the specific options available through the ACA Marketplace as well as the coverage limits and requirements.
ACA Marketplace Coverage
Highmark provides marketplace insurance plans that comply with the Affordable Care Act (ACA). These plans cover some or all costs associated with drug and alcohol rehabilitation programs. Coverage varies by the specific health plan, which may include different amounts and types of treatment options [1]. Highmark plans under the ACA are designed for individuals and families and serve approximately 5.6 million people in Pennsylvania, Delaware, and West Virginia. The plans are categorized into four metal levels that reflect the cost-sharing structure and the level of coverage provided [1].
Overview of Metal Levels
Metal LevelAverage CoverageAverage Out-of-Pocket CostsBronze60%HigherSilver70%ModerateGold80%LowerPlatinum90%Lowest
These categories show how much the insurance covers and how much individuals may have to pay out-of-pocket for rehab services.
Coverage Limits and Requirements
Highmark insurance plans include coverage for mental and behavioral health treatment, inpatient services, and substance abuse treatment, as mandated by the ACA. However, there are specific coverage limits and requirements that beneficiaries must be aware of:
To understand more about the specific requirements for Highmark Blue Shield rehab insurance, individuals should refer to their plan documents or contact customer service directly for personalized assistance. For more detailed insights on coverage offerings, check out the links to other insurance programs such as unitedhealthcare community plan addiction treatment coverage limitations and requirements for aetna better health rehab insurance.
Authorization and Billing
Navigating the authorization and billing process for Highmark Blue Shield rehab insurance is essential for accessing treatment services. Understanding prior authorization requirements and the guidance on the authorization process can help streamline this experience.
Prior Authorization
Highmark requires prior authorization for certain services, procedures, and Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) before the performance of the procedure or service. This authorization must typically be obtained by the ordering provider. However, it is important to note that some authorization requirements may vary by member contract [6].
For effective compliance, providers should utilize platforms like Availity which play a critical role in accessing information about member eligibility and benefits. This ensures that pre-approval aligns with the member's specific benefit plan.
Requirement TypeDescriptionService/ProcedureSpecific services may need prior authorizationDMEPOSEquipment and supplies require authorizationMember ContractRequirements can vary depending on the contract
Authorization Process Guidance
Starting October 1, 2024, all medical prior authorization requests must be submitted through the Availity provider portal. For pharmacy requests, these should continue to be submitted via CoverMyMeds. Providers who do not have access to Availity can utilize the HIPAA Health Services Review (278) electronic transactions for some authorizations.
Highmark's Predictal Auth Automation Hub offers a utilization management tool that facilitates the submission, updating, and inquiries regarding authorization requests, which assists providers throughout the authorization process.
Providers who have questions about authorizations should contact the appropriate number provided in Highmark's documentation or reach out to Provider Services for help with authorization workflows, registration, and portal navigation. By following these guidelines, individuals can effectively navigate the requirements for Highmark Blue Shield rehab insurance while ensuring timely access to necessary treatments.
References
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