This information is issued on behalf of Highmark Blue Shield and its affiliated Blue companies, which are independent licensees o f the Blue Cross Blue Shield Association.
Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield mem bers in 21 counties in central Pennsylvania and 13 counties
in northeastern New York. As a partner in joint opera ting agreements, Highmark Blue Shield also provides services in conjunction with a separate he alth plan in
southeastern Pennsylvania. Highmark Inc. or certain o f its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in w estern Pennsylvania,
13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state o f Delaware and 8 counties in western New York. All
references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
HIGHMARK’S RETROACTIVE CHART RETRIEVAL
PROGRAM
Highmark is performing our Retroactive Chart Retrieval Program for Medicare Advantage (MA) and
Affordable Care Act (ACA) charts. Below are answers to the most frequently asked questions.
Q1:
A1:
Q2:
A2:
Q3:
A3:
Q4:
A4:
Why is Highmark requesting MA and ACA medical record information for the
Highmark Retroactive Chart Retrieval Program?
As a holder of an MA contract and issuer of qualified health plans under the
ACA, Highmark is required to ensure the accuracy and integrity of risk
adjustment data submitted to the Centers for Medicare & Medicaid Services
(CMS).
This review of the medical record documentation is intended to confirm that
complete and accurate documentation exists in support of chronic illnesses and
conditions diagnosed during member encounters. All diagnosis codes submitted
must be documented in medical records as a result of a face-to-face visit. The
diagnosis must be coded according to the CMS International Classification of
Diseases (ICD), Clinical Modification Guidelines for Coding and Reporting.
Did Highmark recently perform a retroactive chart retrieval in our offices?
Yes, it is possible. Due to different timelines for the MA and ACA chart retrieval
review processes, Highmark must conduct chart retrievals multiple times each year,
which may cause an overlap. Chart retrievals for ACA charts took place in October
2021 through March of 2022. Chart retrieval for Highmark MA members is
scheduled to begin this month (April 2022).
Is this an audit?
No, this is not an audit.
Are we req
uired to p
articipate in the Highmark Retroactive Chart Retrieval
Program?
Yes, Highmark requires that requested medical records be supplied per provider
contracts. As a network provider, you are required to submit these records without
charge.
FOR PROFESSIONAL AND FACILITY PROVIDERS
APRIL 8, 2022
