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Important Update:. Whether managing your claims or making informed health care decisions; Highmark can help with easy-to-use online tools. Need a hand? Call Member Service.

Give Member Service a call to find doctors, get details on your health plan, and help you understand your Explanations of Benefits. Use our Provider Search Tool to search for in-network doctors, hospitals, urgent care centers, freestanding diagnostic centers, and more.

You can also take our Doctor Match Quiz to get connected with a doctor who suits your personal style, find top-quality specialty care, compare hospitals, and, for those who may be traveling, search for in-network doctors across the country and around the world. Account contributions are not taxed. Treasury Department.

These guidelines require 1. A member must be enrolled in a qualified HDHP to establish and contribute to a health savings account. I Indemnity Traditional fee-for-service health coverage in which covered health care services received from participating providers are paid-in-full after any applied deductibles, copayments or coinsurance costs have been met.

M Maintenance Drugs A prescription drug prescribed for the control of a chronic disease or illness, or to alleviate the pain and discomfort associated with a chronic disease or illness. Managed Care Health care coverage offered by health plans where there is an organized way for contracting with providers, and processes in place to manage costs, use of services and the quality of the delivery of health care.

Maximum The greatest amount of benefits that the health plan will provide for covered services within a prescribed period of time. This could be expressed in dollars, number of days or number of services. Medically Underwritten Plans that base acceptance for enrollment on health status, determined by the answers given on a medical questionnaire. N Network Group of physicians, hospitals and other health care providers and suppliers contracted with the health plan to offer health care services at negotiated rates.

O Open Enrollment A period each year when a member has the opportunity to change or elect their health care coverage. Out-Of-Network Provider Physicians, hospitals or other health care providers who do not contract with a health plan. Out-of-Pocket Maximum The maximum dollar amount a member is required to contribute towards the cost of covered services in a benefit period. This limit protects a member from very high costs by capping the total amount they will have to pay for covered health care services.

The out-of-pocket limit always includes coinsurance, and may include other cost-sharing amounts such as copayments or deductibles. Some services may be excluded from the out-of-pocket limit such as prescription drug expenses. P Participating Provider A health care provider who has been contracted to give medical services or supplies to health plan members for a pre-negotiated fee on indemnity health care plans.

Pre-Authorization The process in which a member or provider must contact the health plan prior to a non-emergency hospitalization or other selected services, in order to receive authorization for these services. Pre-existing Condition A condition for which medical advice, care, treatment or diagnosis has been recommended or received from a provider within a designated time period immediately preceding the effective date of coverage.

Pre-existing Waiting Period A specified period of time when the health plan does not cover a member's pre-existing condition s. Preferred-Provider Organization PPO Health care coverage that does not require the selection of a primary care physician, but is based on a provider network made up of physicians, hospitals and other health care providers.

A PPO program has two levels of benefits: If a member uses the providers within the network, claims are paid at the higher in-network level of benefits. Services received outside of the network will be reimbursed at the lower, out-of-network level of benefits. Premium Payment or series of payments made to a health plan by a group, an employer or a member for health care benefits.

Preventive Care Preventive benefits that are offered in accordance with a predefined schedule based on age, sex and certain risk factors. Benefits are provided for periodic physical examinations, immunizations and selected diagnostic tests and are covered regardless of medical necessity but have proven clinical value when performed on a routine basis.

Primary Care Provider PCP A health care provider who often serves as a member's first contact with a health plan's health care system and who may supervise, coordinate and provide specific basic medical services while maintaining continuity of patient care. Also known as a primary care physician, personal care physician, or personal care provider.

Programs Based on Income Plans for which the plan member's eligibility is based on income guidelines. Provider A provider is any doctor, specialist, hospital or rehabilitation facility, for example, where a patient gets health care.

Provider's Reasonable Charge Allowable Charge The allowance or payment that the health plan has determined is reasonable for covered services based on the provider who renders such services. The Provider's Reasonable Charge is the portion of the provider's billed charge that is used by the health plan to calculate the payment to that provider and the member's liability.

W Wellness Office Visit A physician's office visit which is not prompted by sickness or injury. Would you like to view these online or schedule an appointment? Enter your starting address. Enter your zip code to continue. Please select your county to continue. You have selected the store. Would you like to schedule an appointment at this location?

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At Highmark, we believe to fix health care we have to put patients first. To deliver the value-based care that patients deserve, we need to change how health care works. Instead of working with practitioners on one side and us on the other, we're partnering with you to provide the most appropriate care possible. Putting patients first means giving members access to high-quality care.

It's about convenience and quality. That's why we constantly work to identify high-performing providers and offer access to alternative care locations such as clinics, local facilities, and in-home care. To that end, Highmark has measured a specific set of performance metrics for components of care provided by participating home health agencies.

As a result of that review, Highmark determined that while all participating home health agencies provide quality care, some providers had higher re-admission rates, higher emergency department utilization and higher than average cost per episode — all of which can lead to higher costs for members. Highmark created a network of home health agencies to align with the commitment to work with healthcare providers to make sure that our members receive high-quality health care that is affordable.

Only those participating home health agencies that performed at the highest levels are included in the High Performance HHA Network. These providers are placed at the highest benefit tier for commercial tiered products using the High Performance HHA Network. Contact Us. Provider Directory. At Highmark, we believe to fix health care we have to put patients first. To deliver the value-based care that patients deserve, we need to change how health care works.

Instead of working with practitioners on one side and us on the other, we're partnering with you to provide the most appropriate care possible. Putting patients first means giving members access to high-quality care. It's about convenience and quality. That's why we constantly work to identify high-performing providers and offer access to alternative care locations such as clinics, local facilities, and in-home care. To that end, Highmark has measured a specific set of performance metrics for components of care provided by participating home health agencies.

As a result of that review, Highmark determined that while all participating home health agencies provide quality care, some providers had higher re-admission rates, higher emergency department utilization and higher than average cost per episode — all of which can lead to higher costs for members. Highmark created a network of home health agencies to align with the commitment to work with healthcare providers to make sure that our members receive high-quality health care that is affordable.

Only those participating home health agencies that performed at the highest levels are included in the High Performance HHA Network. These providers are placed at the highest benefit tier for commercial tiered products using the High Performance HHA Network.

Contact Us. Provider Directory.

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