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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. 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. Many Highmark members now have plans with high deductibles that are tied to corresponding HRAs. Please note that you will have to contact Highmark to determine if the member has met any of the HRA amounts listed. Providers can request that National Imaging Associates Inc. The ordering provider did not contact NIA prior to the service being performed, but calls NIA after the services have been performed.
The performing provider is requesting a retro review because a claim denied based on no authorization being on file. Providers who are not yet NaviNet-enabled must call Highmark Customer Service at , Option 6, after the approved authorization is provided by NIA and request that an adjustment be made. Complete information about the Radiology Management Program and the retrospective review process can be found in the Highmark Radiology Management Program section of the Provider Resource Center.
For more complex issues, the Provider Service telephone lines offer expanded functionality to better serve you. Innovative self-service prompts allow you to get the detailed information that you need quickly and efficiently. Current NaviNet users who have questions about the system may call to speak with a NaviNet representative.
WebOct 1, †∑ For MembersBenefits for AdultsBenefits for ChildrenBenefits for LTSSOnline Doctor Visits: HHO on the GoPharmacy . WebNaviNet Open Medical Authorizations lets provider offices submit and access medical authorizations in real time. This user guide describes how to: Search for an existing . Highmark Blue Cross Blue Shield Support Home. Some of the content on this page is restricted to authenticated users. Click the link below to authenticate. If you have an active session with NaviNet or another NantHealth product, you will be taken directly to the content. Otherwise, you will be asked to enter your username and password.