Learn More. The Peer-to-Peer request must be received by Maryland Amerigroup maryland prior authorization Care within two 2 business days of the initial notification of the denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician. For specific details prioe authorization requirements, please refer to our Quick Reference Guide. Certain carefirst mental providers require prior authorization regardless of place of service.
While Pittsburgh was slowly recovering from the Great Depression in , its hospitals were in trouble. At that time, Blue Cross of Western Pennsylvania unveiled a prepaid hospital plan that would benefit both the hospitals and the people of Pittsburgh.
The plan promised individuals 21 days of hospital service for a monthly premium of 75 cents. A spouse could be added to the plan for an additional 65 cents, and children could be added for 35 cents. Coverage for the first subscribers became effective on January 1, Over 75, members were enrolled within the first year, and by enrollment had increased to , In the s, Blue Cross expanded the benefits offered in its original day hospital contract to cover 50 percent of an additional 90 days of care.
It also introduced "direct-pay" coverage for individuals who were self-employed or otherwise ineligible for participation in a group plan. Blue Cross also encouraged the development of the Medical Services Association of Pennsylvania to provide prepaid coverage for physician fees. This agreement provided uniform Blue Cross and Blue Shield benefits to companies and unions whose operations extended across state lines.
Blue Cross' goal was to provide quality health care to all Pennsylvanians. Unlike many other insurers, Blue Cross continued coverage to its subscribers after they retired. Over the years, Blue Cross began acquiring noninsurance businesses in addition to providing insurance coverage, and in , the organization changed its name to Veritus Inc. Enrollment declined in World War II as many members left the state to support the war. Arthur Daugherty replaced Palmer as president in and recruited new, larger accounts, including the United Mine Workers and the Congress of Industrial Organizations.
In , MSAP became a chapter of the national Blue Shield association, which was started that year by the medical societies. MSAP recruited the , employees of United States Steel in , which brought its total enrollment to more than 1.
Despite the organization's large client base, it had trouble keeping up with its payments to doctors and was forced to raise premiums. The commission suggested that MSAP control costs rather than continue to raise premiums.
In response, MSAP formed a utilization control unit the following year to help keep track of expenses. Two years later, the organization began managing the federal government's Medicare insurance plan for the state's elderly and also started the Special plan to supplement Medicare coverage.
In the s, the organization again fell behind in its payments to doctors. Rates were once again increased and expenses were scrutinized.
Pennsylvania Blue Shield faced serious competition in the s from newly formed health maintenance organizations HMOs within the state. Despite physicians' protests and state regulators' concerns, Pennsylvania Blue Shield merged with Veritus in The new company chose the name Highmark Inc. The merger of Pennsylvania Blue Shield with Veritus, formerly Blue Cross of Western Pennsylvania, was highly controversial, giving Highmark a staggering 60 to 65 percent of the total market share in Western Pennsylvania.
The approval of the merger by the state insurance commission on November 27, shocked those who opposed it. The approval was not without contingencies, however. Kaiser also stipulated that Highmark stay nonprofit for at least two years after its creation. His approval was also contingent upon Highmark providing continued coverage to the poor. In addition, Highmark also could not demand exclusivity from any hospital it contracted. The newly merged Blues had a total enrollment of roughly 2.
Pittsburgh's next largest insurer, HealthAmerica, had only , members. While Highmark brandished a great deal of power, its first year was not an easy one. The organization posted sizable losses in for its most popular product, the Select Blue health plan.
To offset the losses, Highmark launched a plan to entice employers to offer Select Blue as the only point-of-service POS plan for employees. To compensate for the underperforming Select Blue, Highmark cut costs and expanded its dental and vision health care programs.
Highmark maintained both of the former Blues' headquarters--in Pittsburgh and Camp Hill--but it downsized its staff by 4. At Veritus out of 3, employees accepted; at Blue Shield out of 8, employees accepted. Highmark also scaled back its Medicare claims processing business. The government divides the administration of the federally funded Medicare among many different insurance carriers, and prior to the merger, Pennsylvania Blue Shield was the nation's largest Medicare carrier.
However, Highmark found it necessary to cut back on its Medicare claims processing, since the federal government reduced its payment to administer these claims.
The Blues had begun expanding their dental and vision programs before the merger. Highmark's Clarity Vision Inc. Moreover, Highmark significantly increased its dental business when it contracted the families of active military personnel throughout the United States with one of its subsidiaries, United Concordia Companies, Inc.
Some of the plans included in the Highmark Health system include:. Data breaches are not new; however, cybercriminals have recently changed the way they carry out their attacks, making the risks more serious than ever before. However, over that same period, the total number of victims decreased. While this may sound like encouraging news, according to the Identity Theft Resource Center, this is a function of criminals focusing more on stealing specific types of data, such as Social Security numbers, financial account information, and protected health information.
Still, despite the decrease in the number of people affected by data breaches, there are more than million data breach victims per year. Many of these are consumers whose identities are stolen multiple times per year. Data breaches can occur in a number of ways. For example, phishing scams, malware programs and ransomware attacks are all common.
When companies store consumer data, they have an obligation to protect it. Indeed, by maintaining a robust data security system, companies are the only ones who can prevent a cyberattack. It is crucial that companies understand their responsibilities and take them seriously. Unfortunately, many companies have been slow to realize the importance of dedicating a small portion of their profits to taking care of the data they possess. By holding companies accountable for their lax data security measures through data breach lawsuits, consumers can send a message that their privacy is important.
If you receive a data breach letter from Highmark Health, or any other company for that matter, it is important that you give the situation the seriousness it deserves. While you cannot help the fact that your data was exposed to an unauthorized party, you can take preventative steps to reduce the likelihood of becoming victimized further. Determine What Information of Yours Was Exposed: Your first step should be to carefully read the data breach letter to determine what type of information was affected.
Be sure to keep a copy of the data breach notification for your records. We offer free consultations to victims of data breaches and can explain your rights in clear, understandable terms so you can make an informed decision about how to proceed with your case. If you decide to bring a case, we only get paid if you do.
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Jun 9, · ® Highmark is a registered mark of Highmark Inc. © ® Highmark is a registered mark of Highmark Inc. © Important Legal Information: Health care benefit . Highmark Inc. is a health and wellness organization located in Pittsburgh and operates health insurance plans in Pennsylvania, Delaware, and West Virginia. Medicare For Providers . WebHighmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of .