Highmark wholecare prior authorization

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October 1 — March 31, 8 a. Please note that a representative may contact you to confirm receipt of information. By providing your email you will receive confirmation of your request as well as other helpful information from Highmark Wholecare. Enrollment in these plans depends on contract renewal. Highmark Wholecare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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.

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

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. The authorization is typically obtained by the ordering provider. Some authorization requirements vary by member contract. This information should not be relied on as authorization for health care services and is not a guarantee of payment. 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.

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:.

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.

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Apply for Benefits. Enrollment in these plans depends on contract renewal. 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. 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. While we accept most major insurance, in-network status may vary by state and center. Prior authorization requests for beneficiaries who receive their pharmacy benefits through the Fee-for-Service delivery system should be directed to the DHS Pharmacy Services division. We have a number of step-by-step reference guides available to assist providers in the authorization process:. Questions about authorization workflows. We strive to provide you with the best possible experience, including the insurance process. Additional information regarding quantity limits for beneficiaries who receive their pharmacy benefits from one of the HealthChoices or Community HealthChoices MCOs is available directly from each MCO. Main Menu. Give us a call at TTY 7 days a week, 8 a. You also explicitly consent to the automated decision making by us, which may include the processing of your health data, to the extent that it is necessary to process your health claim swiftly and efficiently. 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.

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. The authorization is typically obtained by the ordering provider.

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 All preferred drugs that require clinical prior authorization remain available to MA beneficiaries when found to be medically necessary. The Statewide PDL is not the same as the formularies that are commonly used by commercial insurers. Invalid format. We strive to provide you with the best possible experience, including the insurance process. Benefit plans vary widely and are subject to change based on the contract effective dates. Apply for Benefits. Requiring Authorization. MedExpress Color Block. If you have questions regarding how we process your Personal Data and what we store about you, please contact PrivacyInternational HighmarkHealth. Contact Us.