How can you assist us in safeguarding your health care dollars? Watch out for red flags that could indicate potential fraud. If you suspect potential health care fraud, please let us know.
Some of the factors that could indicate potential fraud include:
Resubmitting denied claims (e.g. billing for the same services using a different procedure code after the first procedure was denied)
Billing for services that aren't covered by coding the service as a procedure that is a covered service
Altering claims or patient record (e.g. date inserted, items handwritten when the rest of claim isn't)
Misusing or misspelling medical terms
Listing services as rendered in another state or on a holiday or weekend
Submitting multiple billings for the same service
Billing for services that haven't been rendered
Billing for an amount that doesn't correspond to the services rendered
Altering receipts or claims
Using the same last name for both the provider and the patient (most benefits list an exclusion of providers billing for the treatment of family members)
Circumventing benefit exclusions (patient exhausts all physical therapy benefits and the provider continues to render physical therapy services and bills them as an office visit or submits the physical therapy services under the spouse's name)
Submitting high dollar claims (e.g. charges for the service being billed are out of the ordinary)
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.
This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal.
®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which 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.
PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418.
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. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card.
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.
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