Highmark Blue Cross Blue Shield of Western New York
New York • Medicare Advantage, High-Deductible Health Plan (HDHP), EPO
Medicare Advantage coverage under this prefix means the plan administers Medicare Part A and Part B benefits on behalf of CMS. These claims may have different processing rules than commercial claims, including different prior authorization requirements and appeal timelines. CMS timely filing rules (365 days) typically apply.
HDHP (High-Deductible Health Plan) coverage means the member has a higher deductible than traditional plans, often paired with a Health Savings Account (HSA). Most services require the member to pay out-of-pocket until the deductible is met. Preventive care is typically covered before the deductible. Submit claims normally to the payer listed above.
This prefix is associated with an EPO plan. Exclusive Provider Organization coverage combines elements of HMO and PPO plans: members must stay in-network like an HMO, but can self-refer to specialists like a PPO. Out-of-network services are not covered except for emergencies.
Highmark Western and Northeastern New York Inc. providing commercial, Medicare and Medicaid plans in Western New York region.