Authorization Updates

AuthorizationDuring the year, Highmark adjusts the List of Procedures and Durable Medical Equipment (DME) Requiring Authorization. For information regarding authorizations required for a member’s specific benefit plan, providers may:

  • Call the number on the back of the member’s card,
  • Check the member’s eligibility and benefits via NaviNet® , or
  • Search BlueExchange through the provider’s local provider portal.


Authorization changes are announced in the form of Special Bulletins posted on Highmark’s Provider Resource Center (PRC). The most recent Bulletins regarding prior authorization are listed below:

Effective Date(s) Title
October 20, 2022 Authorization Letters Available in NaviNet for Inpatient Services
November 1, 2022 Prior Authorization No Longer Needed for Glimepiride and Glyburide
November 7, 2022 Authorizations Section Added To Provider Resource Center
November 18, 2022 Enhancements to eviCore Authorization Process
November 23, 2022 Outpatient Services, Ancillary, DME And eviCore Authorizations Routed to New Utilization Management Tool
December 1, 2022 New Go-Live Date! Authorizations Required for OOA And OON Musculoskeletal, Genetic Testing, and Radiation Oncology Services
December 9, 2022 Echocardiogram Code to Be Removed From Prior Authorization List
December 31, 2022 Sunsetting: WholeHealth Living’s Rapid Response System Interactive Voice Response Option For Authorizations
February 2023 MCG Chosen as Utilization Management Clinical Criteria Vendor
January 1 and April 1, 2023 Upcoming Prior Authorization Changes
March 1, 2023 Two Injectables to Require Prior Authorization Beginning March 1, 2023

To view the full List of Procedures/DME Requiring Authorization, click Requiring Authorization in the gray bar near the top of the PRC homepage.

The Highmark member must be eligible on the date of service and the service must be a covered benefit for Highmark to pay the claim.

NaviNet® is the preferred method for:

  • Checking member benefits and eligibility
  • Verifying whether an authorization is needed
  • Obtaining authorization for services

The new Authorizations section on the PRC features forms and a complete list of procedures and services requiring authorization. To access the section, go to the PRC and click on AUTHORIZATIONS from the left menu.

 

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