Self-Service Tools

We value your participation with Highmark and the quality service you provide to our members. We have made significant investments in our self-service tools to reduce administrative burden, improve office workflows, and simplify complex transactions — allowing you and your staff to focus on delivering care to our members.

As a result of this evolution, Highmark requires providers to utilize our enhanced self-service tools to obtain the fastest resolution to many common issues and tasks. This allows our Provider Service advocates to assist with more complex issues and your staff avoid unnecessary hold times on the telephone.

Highmark’s Provider Resource Center (PRC): You are here! The PRC is the main hub for you and your staff to review important information and tools, such as EFT registration, policies, procedures, and the Provider Manual.

Availity Essentials, Highmark’s Provider Portal: The primary method to submit transactions to Highmark and access reports:
- Value Insights Center (Value-Based Program Reporting Tool)
- Credentialing (Initiate Application, Submit Change, Review Status)
- Eligibility and Benefits Check
- Authorization Submission
- Claim Submissions/ Investigations – The use of Availity to check claim status and submit a claim investigation is required.

Interactive Voice Response (IVR) System: The Provider Service Center offers options for you to access information, such as claim status or member benefits, without a live agent.

Our wide range of self-service tools available 24/7. Use the below chart as a reference if you are unsure of where to start. Download here.

Topic(s)	Inquiry Examples	1st Level		2nd Level
		Self Service (required for many transactions)		Provider or Clinical Service
Authorization Appeals / Grievances	•Confirm status of retrospective reviews and appeals •Appeal sent but not received •Disputing decision	Availity: Status check for Retrospective Reviews & Appeals Peer-to-Peer: (866) 634-6468 to schedule		Contact Regional Provider Service: Contact Page
Authorization & Pharmacy	•Urgent or non-urgent prior authorization requests •Post-acute discharge •Check authorization status	Availity: Submit authorization, check status or make changes Portal Submission Guides: Inpatient Authorization Submission (Both Urgent and Non-Urgent); Outpatient Authorization Submission		Contact Clinical Services or Pharmacy: Contact Page (If services are within 72 hours, Post-Acute or Pharmacy related)
Claims	•Claim didn’t process correctly or according to expectation •Adjustment has not been completed timely •Submitted adjustment bill and claim has been rejected as duplicate rather than adjustment •Status of submitted claim	Availity: Claims inquiries/direct messaging (including follow-up to an initial inquiry) Interactive Voice Response: Can be used to check claims status (Contact Page)
Contracting	•Contract payment was made incorrectly	Contact Regional Provider Service: Contact Page
Eligibility & Benefits	•View member ID card •Member cost share •Deductible renewals •New benefit year information	Availity: Benefits and eligibility check		Contact Regional Provider Service: Contact Page
Medical Policy	•Medical necessity and coverage guidelines •Coding guidance	Provider Resource Center: Commercial Medical Policy Search Tool Delaware; New York; Pennsylvania, West Virginia (Highmark adheres to the Centers for Medicare and Medicaid Services coverage determinations for Medicare Advantage membership.)		Contact Regional Provider Service: Contact Page
Remittance	•Didn’t receive file for claims payment •Don’t understand file •Didn’t get payment file (EFT)	NY	Highmark EDI: (800) 992-0246 Highmark EDI: Satisfaction Survey	Contact Regional Provider Service: Contact Page
		DE, PA, WV	ECHO Support: (800) 890-4124 ECHO: User guide

Last updated on 5/8/2024 11:17:11 AM

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.

Quick Links:

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Highmark Provider Manual

Medical Policy Search Medical Policy Search

Medical Policies

Medicare Advantage Medical Policies

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Requiring Authorization

Pharmacy Policy Search

Self-Service Tools

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