Highmark will pay for care by more than one physician for treatment of hospital or skilled nursing facility in patients when the physicians are treating two or more separate conditions or the severity of the single condition requires the services of two or more physicians. The medical records should:
– Document the primary physician’s request for the consult(s)
– Document the seriousness of the medical condition
Concurrent Medical Care Guidelines
The admitting physician should be responsible for the patient’s primary care. He or she may be paid for medical care unless the patient is transferred to a consultant or specialist.
When two or more physicians each submit claims with multiple diagnoses on an inquiry basis, Blue Cross Blue Shield will evaluate each claim for payment or denial based on the conditions that each physician was treating.
Payment may be made for the concurrent treatment of two or more separate conditions by physicians of different specialties.
Payment may not be made for the concurrent treatment of two or more separate conditions by physicians of the same specialty.
Payment may not be made for the concurrent treatment of the same condition by physicians of the same specialty.
Payment may not be made for the concurrent treatment of the same condition by physicians of different specialties.
Highmark reminds billing physicians to report only the diagnosis which they are treating to avoid confusion in the claims adjudication process.
