Understanding Highmark BCBS Prior Authorization for Members

Highmark Blue Cross Blue Shield (BCBS) requires prior authorization for certain medical services to ensure that they are medically necessary and provide the best possible care for their members.

If you're a Highmark BCBS member, you may need to get prior authorization before receiving certain treatments or services.

Highmark BCBS uses a list of approved treatments and services to determine which ones require prior authorization.

This list includes services like chemotherapy, physical therapy, and certain surgical procedures.

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Prior authorization is an essential step in ensuring that Highmark BCBS covers the medical services you need. You can request prior authorization at least 14 days in advance, or as soon as possible, for planned admissions or services.

The authorization request process involves submitting required information via Availity or HIPAA 278, which is the preferred method. This process is quick and easy to perform, making it a convenient option for providers.

To submit a prior authorization request, follow these steps:

Highmark encourages providers to use the Availity system or HIPAA 278 electronic transactions to submit authorization requests. This is the preferred method, and it's fast and easy to use.

If you prefer to submit your request by fax, you can complete the submission directions on the form provided by Highmark. You can also use the Medical Forms Resource Center (MFRC) or My Insurance Manager online tools to submit prior authorization requests.

For emergency admissions, it's essential to obtain an authorization within 48 hours of the admission or as soon as possible. This applies to childbirth-related admissions as well, where the provider must contact Highmark within 48 hours after an emergency admission or for lengths of stay longer than 48 hours after a vaginal delivery or 96 hours after a C-section delivery.

Member Eligibility and Benefits are crucial to the prior authorization process. Service preapproval is based on the member's benefit plan/eligibility at the time the service is reviewed/approved.

Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits.

A unique perspective: Eligibility Verification & Prior Authorization

To verify eligibility and benefits, providers can access Availity, Highmark's provider portal, or call the number on the back of the member's identification card. Out-of-area providers can check for the member's benefits through BlueExchange in their local portal.

Eligibility and benefits can also be verified through the online provider portal or by calling the number on the member's identification card. This ensures that the provider is aware of the member's current benefits and any authorization requirements.

Providers are responsible for confirming that the member's benefit plan provides the appropriate benefits for the anticipated date of service. This can be done electronically via Availity's Eligibility and Benefits Inquiry or by submitting a HIPAA 270 transaction.

Expand your knowledge: Availity Phone Number for Prior Authorization

Highmark BCBS Prior Authorization Code Lists and Criteria are used to determine the medical necessity and appropriateness of healthcare services. These lists are subject to change, and Highmark provides written notice when codes are added or deleted.

To view the lists of procedures that require prior authorization, you can visit the Highmark website and click on the links provided. The lists include procedures such as behavioral health intensive outpatient and partial hospitalization, potentially experimental and cosmetic procedures, and select durable medical equipment.

Highmark uses MCG Clinical Criteria, which are evidence-based clinical guidelines, to assess the medical necessity and appropriateness of healthcare services. Additionally, Highmark Medical Policy and Medicare Advantage Medical Policy are used to evaluate the medical necessity and appropriateness of healthcare services.

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Highmark maintains lists of procedures and durable medical equipment (DME) that require authorization. These lists are subject to change, with new codes added and old ones deleted throughout the year.

To view the lists, you can visit the Provider Resource Center. From there, select Claims & Authorization from the main menu, and then Authorization Guidance.

The lists include services such as behavioral health intensive outpatient and partial hospitalization, potentially experimental and cosmetic procedures, select DME, and certain outpatient procedures and supplies.

Here are some examples of services that require authorization:

Certain employer groups may opt out of this requirement, and self-funded accounts, government programs, and other groups with non-standard benefits may have their own lists of services requiring authorization.

Highmark uses MCG Clinical Criteria to inform their clinical decision support.

Highmark incorporates MCG Health evidence-based clinical guidelines into their clinical decision support criteria, which helps ensure that patients receive the best possible care.

Highmark Medical Policy and Medicare Advantage Medical Policy are used to assess medical necessity and appropriateness of health care services, including inpatient care.

For inpatient care, Highmark also uses MCG Care Guidelines to assess acute adult, acute pediatric, acute rehabilitative, long-term acute, skilled nursing, and home health services.

These criteria are applied in conjunction with applicable Highmark Medical Policy and CMS Medicare Advantage Medical Policy to ensure comprehensive assessment of medical necessity and appropriateness of services.

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MSK and IPM procedures require prior authorization, starting October 1, 2018.

This means that musculoskeletal surgical procedures and interventional pain management services now need approval before they can be performed.

The Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program is managed by eviCore.

Additional information about this program can be found on the Provider Resource Center under Policies & Programs then Care Management.

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Highmark has partnered with eviCore healthcare (eviCore) for several Care Management Programs. These programs aim to improve patient outcomes and reduce healthcare costs.

Highmark's Care Management Programs include the Advanced Imaging and Cardiology Services Program, Laboratory Management Program, Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program, and Radiation Therapy Authorization Program.

For more information on these programs, visit the Policies & Programs section and select Care Management.

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Highmark has partnered with eviCore healthcare (eviCore) for several care management programs. These programs aim to improve patient care and outcomes.

One of the programs is the Advanced Imaging and Cardiology Services Program. This program is designed to help manage advanced imaging and cardiology services.

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The Laboratory Management Program is another program that helps manage laboratory services. This program ensures that laboratory tests are necessary and cost-effective.

The Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program is a program that requires prior authorization for musculoskeletal surgery and interventional pain management services. This program helps prevent unnecessary procedures.

Radiation Therapy Authorization Program is a program that requires authorization for radiation therapy services. This program helps ensure that radiation therapy is necessary and safe.

Highmark's Care Management Programs can be found under Policies & Programs and then Care Management. This section provides information on all of Highmark's care management programs.

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Physical medicine services require prior authorization, and you can find information about them on the Provider Resource Center.

The Provider Resource Center has a section called Policies & Programs where you can look for care management information.

To access this information, select Policies & Programs on the Provider Resource Center.

This will lead you to a section called Care Management where you can find details about physical medicine services that need prior authorization.

You can find this information by looking under Care Management on the Policies & Programs page.

The Radiation Therapy Authorization Program is a great resource for providers who need to know what services require prior authorization.

You can find additional information on radiation therapy services that require prior authorization on the Provider Resource Center.

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Inpatient Admissions require authorization for various facilities.

Authorization is required for all inpatient medical services, including acute care hospitals, long-term acute care hospitals (LTAC), and rehabilitation hospitals. These facilities provide critical care and treatment for members.

You'll also need authorization for skilled nursing facilities (SNF) and mental health or substance abuse treatment facilities. These settings offer specialized care and support for members with specific needs.

Here are the specific facilities that require authorization for inpatient admissions:

Highmark BCBS has a list of procedures and services that require prior authorization to ensure patient safety and optimized treatment. This list includes behavioral health intensive outpatient and partial hospitalization services, except in New York where a prior authorization is not required for outpatient services.

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Highmark continuously updates this list, adding and deleting procedures as needed. You can find the most up-to-date list by visiting the Provider Resource Center and selecting Claims & Authorization from the main menu.

The list includes potentially experimental, experimental, and cosmetic procedures, as well as select durable medical equipment (DME), injectable drugs, and oxygen services. Certain employer groups may opt out of this requirement, and self-funded accounts, government programs, and other groups with non-standard benefits may have their own lists of services requiring authorization.

To determine if prior authorization is required for a specific service, you can use the Availity Eligibility and Benefits Inquiry or the applicable HIPAA electronic transaction for benefit verification.

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Highmark requires prior authorization for inpatient admissions and certain outpatient services from out-of-network providers with commercial coverage. This applies to both in-network providers who are not participating in the member's network and out-of-area providers who are not participating with their local Blue Plan.

Out-of-network providers are defined as those within Highmark's service area but not participating in the member's network, or out-of-area providers located outside of Highmark's service area who are not participating with their local Blue Plan. Members seeking services from out-of-network providers will be responsible for working with their provider to obtain the necessary authorizations.

Prior authorization is not required for outpatient services managed by eviCore, a partner vendor of Highmark. Members should check the Provider Resource Center for more information on this program.

Highmark requires that out-of-network inpatient and outpatient services be deemed medically necessary prior to payment for Medicare Advantage members. Providers or members can contact Highmark to request precertification of coverage from the plan prior to performing or receiving a service to determine whether or not it would be considered medically necessary.

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Electronic requests are the preferred method for submitting authorization requests to Highmark. Availity is the go-to platform for this purpose.

To submit electronic authorization requests, you can use Availity or the HIPAA 278 electronic transaction. The HIPAA 278 transaction requires you to refer to the Provider EDI Reference Guide, which can be accessed from the Provider Resource Center.

Electronic submission is the preferred method, and it's quick and easy to perform. This method is especially recommended for submitting authorization requests for inpatient admissions, medical and behavioral health services.

You can submit authorization requests through Availity or the Highmark EDI Trading Partner Business Center. To access the EDI Trading Partner Business Center, select Resources from the menu on the home page.

Highmark provides an automated process via Availity for submitting authorization requests for medical and behavioral health inpatient care and inpatient/post-acute transfers. This process uses interactive MCG Care Guidelines.

Here's a summary of the electronic submission options:

Keep in mind that you must be licensed and board certified or board eligible and qualified to practice in the specialty area appropriate for the treatment needed when requesting prior authorization.

If an authorization is granted, Highmark will notify the member and requesting provider within the required time frame.

The notification will include a reference number that the provider can use in referencing the authorization, which is crucial for future claims.

In concurrent review cases, the notification will include additional details such as the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

If the authorization is denied, Highmark will issue written notification to the member and requesting provider, except in New York where both verbal and written notification will be sent.

The written notification will include the principal reason(s) for the denial, reference to the plan provision on which the determination is based, and a description of any additional information necessary to make the determination.

The notification will also include an explanation of why the additional information is necessary, a description of procedures and time frames for appealing the denial internally and externally, as applicable, and a statement that a copy of the clinical review criteria relied upon will be provided free of charge upon request.

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Additionally, the notification will include a statement that an explanation of the scientific or clinical basis for the determination as it relates to the member’s medical condition (clinical rationale) will be provided free of charge upon request.

Here are the key points to note about denial notifications:

Pre-certification is a crucial step in the addiction treatment process with Highmark BCBS. You can find a list of procedures requiring authorization on Highmark's website, specifically at the Provider Resource Center and the Behavioral Health Provider Portal.

Highmark has a specific list of outpatient CPT addiction treatment codes that require authorization, including H0012, H0013, H0017, H0018, H0019, H0022, H0043, H0047, H2001, H2012, H2013, H2022, H2036, and T2048.

If you're a provider, you can easily reference what CPT codes need authorization or precertification at Highmark using the provided screenshot of the authorization list.

To request pre-certification or authorization with Highmark, you can use the ACM functionality on the NaviNet system, fill out an old-fashioned authorization form and submit it via fax, or contact Highmark directly via phone.

Here are the contact numbers for behavioral health pre-certifications by state and region:

For Federal Employee Program (FEP) prior authorization requirements, precertification is required for inpatient hospital, residential treatment center (RTC), and skilled nursing facility admissions.