Short Takes: Medical Review Committee, High Performing Provider Program, & More

Medical Review Committee Members Needed – Apply by Aug. 2

Highmark is seeking members to serve on its Medical Review Committee for the upcoming two-year term of 2025–2026. All potential candidates must be a Pennsylvania licensed health care provider with one or more professional provider contracts with Highmark.

If you are interested in being considered for membership by the Medical Review Committee Selection Committee, please email a copy of your current resume or curriculum vitae, by Aug. 2, 2024, to or mail to the address below:

Earl Bock
Secretary, Medical Review Committee
Financial Investigations and Provider Review
Highmark Inc.
1800 Center Street, Mailstop FIPR
Camp Hill, PA 17011

Physical Medicine Management: New High Performing Provider Program

On Jan. 1, 2025, Highmark will launch its High Performing Provider (HPP) Program for practitioners who provide outpatient physical therapy and occupational therapy services. The HPP Program allows greater self-management for providers who meet certain performance metrics. To learn more, go here.

How to Submit Prior Authorization Requests for Outpatient Physical Medicine Services

Prior authorization is required for outpatient physical medicine services. When requesting prior authorization for these services via the Predictal™ Auth Automation Hub in Availity®, providers must select “Physical Medicine” as a Sub-Service Type. For step-by-step instructions, click here.

Latest Edition of MCG Guidelines – Aug. 1, 2024

The 28th edition of MCG’s Care Guidelines will be available on Aug. 1, 2024.

After that date, you will be able to submit authorization requests using the 28th edition for any new requests. Any authorization requests with a start of care date prior to Aug. 1, 2024, will be reviewed using the 27th edition.

Please continue to use the Predictal application in Availity® to submit authorization requests with clinical information included.

ASAM 4th Edition to be Implemented on July 1

Effective July 1, 2024, Highmark will transition from the American Society of Addiction Medicine (ASAM) Criteria 3rd Edition to the ASAM Criteria 4th Edition. Highmark uses ASAM criteria to review authorization requests for substance abuse services.

To learn more about the ASAM Criteria 4th Edition, go here.