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Prior Authorization Changes for Highmark Blue Cross and Blue Shield Members

Effective November 1, 2020, Highmark is expanding our prior authorization requirements for outpatient services to include those services provided by out-of-area providers participating with their local Blue Plan.  This will ensure that the care our members receive while living and traveling outside of the Highmark service area is medically necessary and managed as consistently as it is within our service area.

  • This expands upon our changes made effective 1/1/20 to include enforcement of prior auth requirements for non-contracted providers (both in our local footprint of Pennsylvania, Delaware and West Virginia as well as those outside of our service area)
  • As of 11/1/20 prior authorization requirements will be enforced outside of the Highmark service area regardless of whether the provider is contracted with the local blue plan or not.  Certain exceptions may apply based on group specific options.
  • Providers are encouraged to contact Highmark in advance of services to ensure services provided are deemed medically necessary.  To assist with this, Highmark is enabling our NaviNet® portal functionality to accept authorization requests for outpatient services from out-of-area Blue Plan providers when submitted via their local portals.  The Utilization Management team can also be contacted by using the number provided on the back of our member’s ID card.
  • If the covered services are determined to be medically necessary and appropriate, claims will be paid in accordance with the member’s benefit plan.  If the covered services are not medically necessary or no request for review has been made, no payment will be made.
  • Claims without authorizations will be rejected.  We will contact the local blue plan and request that medical records be sent to allow for review and a medical necessity determination to be made.
  • Outpatient services requiring prior authorization can be found on the Highmark Provider Resource Center.

Please see the attached bulletin for further details.

If you have any questions regarding this newsletter, please contact your BCBSKS provider consultant.