Highmark wholecare prior authorization

October 1 — March 31, 8 a.

This information will be used for purposes of performing services to, or on behalf of, our enterprise customers and prospective customers as part of and in relation to matters regarding our provider, health plan, and subsidiary enterprise care delivery, administration and operations. Your email address and phone number may be used to contact you. All reasonably appropriate measures will be taken to prevent disclosure of your Personal Data beyond the scope provided directly or indirectly herein or as may be reasonably inferred from the content contained in this notice or the website. Your Personal Data will be disclosed to appropriate personnel for purposes of performing services to, or on behalf of, our enterprise customers and prospective customers as part of and in relation to matters regarding our provider, health plan, and subsidiary enterprise care delivery, administration and operations. Notwithstanding the above disclosures, we will disclose the Personal Data we collect from you under the following circumstances:. We use third-party service providers to process Personal Data, including, without limitation, for information storage and other similar purposes. These services providers are located in the United States.

Highmark wholecare prior authorization

When considering medications from a class included on the Statewide PDL for MA beneficiaries, providers should try to utilize drugs that are designated as preferred. Drugs designated as non-preferred on the Statewide PDL remain available to MA beneficiaries when determined to be medically necessary through the prior authorization process. The Statewide PDL is a list of medications that are grouped into therapeutic classes based on how the drugs work or the disease states they are intended to treat. The committee's recommendations are approved by the secretary of the Department of Human Services DHS prior to implementation. The Statewide PDL is therapeutically based. The committee's recommendations are based on the clinical effectiveness, safety, outcomes, and unique indications of all drugs included in each PDL class. When drugs within a class are clinically equivalent, the committee considers the comparative cost-effectiveness of the drugs in the class. Back to Table of Contents. All non-preferred drugs on the Statewide PDL remain available to MA beneficiaries when found to be medically necessary. All drugs designated as non-preferred on the Statewide PDL require prior authorization through the beneficiary's pharmacy benefits provider. Some preferred drugs on the Statewide PDL require a clinical prior authorization. All preferred drugs that require clinical prior authorization remain available to MA beneficiaries when found to be medically necessary.

While we accept most major insurance, in-network status may vary by state and center.

Services centered around you. The services you need to keep your employees healthy. At MedExpress, we understand that accidents and illness can happen anytime. See the information below to help plan your visit to your MedExpress neighborhood medical center. Some exclusions may apply for select insurance plans. We strive to provide you with the best possible experience, including the insurance process. While we accept most major insurance, in-network status may vary by state and center.

As a provider, you have access to a wide variety of tools and resources designed to help you deliver better service. If you haven't already done so, follow these simple steps to get the most out of your Highmark Wholecare partnership. Join our network by completing this form. Login to the provider portal. Review and download Medicare Assured and Medicaid Policies. Check out the Provider Newsletter. Highmark Wholecare participating providers have access to our Provider Authorization Portal. Simply access the portal by clicking here. The new Authorization Portal was integrated into the Highmark Wholecare platform that includes all of the functionality of the original and also includes features such as:. The Department Of Health And Human Services is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.

Highmark wholecare prior authorization

Starting January 1, , Highmark Wholecare will no longer require prior authorization for over services. A listing of the affected Medicare and Medicaid services can be found on our website here. We value your continued partnership and hope this update will help add administrative efficiencies. If you have any questions, please reach out to your Provider Account Liaison. 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. You're being redirected to the CMS search site. Quick Links: Manuals. Medicare Provider Manual. Medicaid Provider Manual.

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If you are not satisfied with our data processing you have the right to lodge a complaint to the data protection authority in your country of residence. Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu. Department of Human Services. Invalid format Required. Quick Links: Manuals. We use third-party service providers to process Personal Data, including, without limitation, for information storage and other similar purposes. MedExpress Main Nav. We have a number of step-by-step reference guides available to assist providers in the authorization process: Availity Guides: Inpatient Authorization Submission Both Urgent and Non-Urgent Outpatient Authorization Submission We also have resources available for Physical Medicine Management authorizations , which transitioned to Highmark managed in December Please enable scripts and reload this page. Utilization management of physical medicine services is now managed by Highmark. All non-preferred drugs on the Statewide PDL remain available to MA beneficiaries when found to be medically necessary. In Medicaid, the list of covered drugs is determined by CMS and is based on whether the manufacturer agrees to pay the federally mandated Medicaid drug rebate. Pharmacy Policy Search. Employer Services The services you need to keep your employees healthy. Apply for Benefits.

Introducing a new provider resource experience that simplifies getting you the information you need, when you need it. Your feedback is appreciated as we work to complete the experience.

Highmark will provide written notice when codes are added to the list; deletions are announced via online publication. Additional Resource: MCG Guidelines Product Acronym List Fax: If you are unable to use the online provider portal, you may also fax your authorization requests to one of the following departments. Contact Us. Employer Services The services you need to keep your employees healthy. For additional information regarding your specific plan and coverage, please contact your insurance provider directly. Powered by Insightin Health. Your feedback is appreciated as we work to complete the experience. Main Menu. Your email address and phone number may be used to contact you. Your Personal Data will be disclosed to appropriate personnel for purposes of performing services to, or on behalf of, our enterprise customers and prospective customers as part of and in relation to matters regarding our provider, health plan, and subsidiary enterprise care delivery, administration and operations. Highmark Provider Manual. Check nearest location: Find the center. Portal : The preferred - and fastest - method to submit preauthorization requests and receive approvals is the online provider portal. The committee's recommendations are based on the clinical effectiveness, safety, outcomes, and unique indications of all drugs included in each PDL class.