Highmark blue shield prior authorization list

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As a reminder, it is always important to check eligibility through Availity TM or your preferred web vendor prior to rendering services; this step will help you determine if prior authorization is required. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits section of our provider website.

In addition to those care categories that already require prior authorization, for members who have the health advocacy solutions or Wellbeing Management service options eligibility and benefits should be reviewed for the following care categories to determine if authorization is required through BCBSNM or eviCore:.

Refer to the educational Availity Authorizations User Guide , located in the Provider Tools section of our website for navigational assistance. Prior authorization for care categories authorized through eviCore can be obtained by accessing the www. Services performed without prior authorization may be denied for payment. As a contracted provider, you may not seek reimbursement from members if your claim is denied for failure to preauthorize or otherwise.

You may also contact your Provider Network Representative for more information. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or eviCore. If you have any questions about the products or services provided by such vendors, you should contact the vendor s directly.

Services requiring prior authorization through AIM are outlined below. Medical records may or may not be needed for pre or post service reviews using the AIM portal due to the smart clinical algorithms within the portal. Member benefits will vary based on the service being rendered and individual and group policy elections. This step will help you confirm coverage and other important details, such as prior authorization requirements and vendors, if applicable. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

These lists are not exhaustive. The presence of codes on these lists does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply. Review categories below to find out if a member's procedure may require prior authorization.

All rights reserved. Use the search below to find out if you require prior authorization or not. Your procedure can fall under one of the 3 categories shown below. Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of a service is not a guarantee of payment of benefits. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

Welcome Employers Producers Providers. Prior Authorization. Providers may submit the NM Uniform Prior Authorization Form electronically through Availity by attaching it during the request process.

Fax request — Complete the Prior authorization Request form or the NM Uniform Prior Authorization Form and submit it along with your supporting documentation Telephone Inquiries — Call the prior authorization number on the back of the member's ID card. Or, call our Health Services department at or Recommended Clinical Review is not a different process and will not generate a different result than a predetermination.

Electronic request — Submit requests online using Availity's Attachments tool. Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu. Authorization number not appearing, unable to locate member, questions about clinical criteria screen. Contact Us. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania.

Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania.

Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies. Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Authorization Requirements. Inpatient admissions e. Inpatient Authorization Guide : Click here for the Predictal step-by-step inpatient authorizations reference guide. Outpatient Authorization Guide : Click here for the Predictal step-by-step outpatient authorizations reference guide.

Questions about authorization workflows. Check status of submitted authorizations.

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The provider is responsible for verification of member eligibility and covered benefits. Effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication. Examples of services that may require authorization include the following.

This is not an all-inclusive list. Benefits can vary; always confirm member coverage. The online portal is designed to facilitate the processing of authorization requests in a timely, efficient manner. If you are a Highmark network provider and have not signed up for NaviNet, learn how to do so here. Highmark recently launched a utilization management tool, Predictal, that allows offices to submit, update, and inquire on medical inpatient authorization requests.

Fax: If you are unable to use NaviNet, you may also fax your authorization requests to one of the following departments. The associated preauthorization forms can be found here.

Telephone: For inquiries that cannot be handled via NaviNet, call the appropriate Clinical Services number , which can be found here. Highmark contracts with WholeHealth Networks, Inc. Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu. Authorization number not appearing, unable to locate member, questions about clinical criteria screen.

Contact Us. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania.

Quick Links: Manuals. Highmark Provider Manual. Provider Directory. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Quick Links: Manuals. Highmark Provider Manual. Medical Policy Medical Policy. Medical Policies.

Medicare Advantage Medical Policies. Requiring Authorization. Pharmacy Policy Search. Message Center. Manuals Highmark Provider Manual. Authorization Requirements. Inpatient admissions e. Inpatient Authorization Guide : Click here for the Predictal step-by-step inpatient authorizations reference guide. Outpatient Authorization Guide : Click here for the Predictal step-by-step outpatient authorizations reference guide.

Questions about authorization workflows. Check status of submitted authorizations. Site Map Legal Information. NaviNet Portal. Authorization Workflows.

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