Highmark prior authorizxation form

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View our Medicare Advantage page or individual plans page for additional appeal forms. Policy reconsideration - Request reconsideration of a coding policy.

Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim. For more details, see our corrected, replacement, voided, and secondary claims section. Support document cover sheet - Submit medical records or other required supporting documentation to process a claim. Incident questionnaire - Use when a patient has sustained an injury or was involved in an accident. Other coverage questionnaire enrollment - Provide information about a patient's other healthcare coverage.

Balance billing protection act dispute — Providers or facilities not contracted with Premera can submit a balance billing dispute request. The form must be received by Premera within 30 days from receipt of the original payment notification.

Find out more about the Balance Billing Protection Act. Overpayment notification - Notify Premera of an overpayment your office received. Use this form for your documentation purposes. Admission notification and discharge notification. Learn more about submitting prior authorization , including for DME. General prior authorization request.

Out-of-network exception request - Request in-network benefits for an out-of-network service. Durable medical equipment DME. Total joint replacement exception request - Specific to Washington small group members requesting a provider or facility that isn't a Premera-Designated Center of Excellence for total knee or hip replacement.

Pharmacy pre-approval request. Opioid attestation — Specific to School Employees Benefits Board SEBB members undergoing active cancer treatment, hospice, palliative care, end-of-life, or medically necessary care who might be exempt from quantity limits. For expedited authorization codes, call Premera pharmacy services at ProviderSource is free and requires:.

View our practitioner credentialing checklist or the Join Our Network page for more information. Behavioral health specialty addendum - Provide us with your behavioral health primary areas of clinical expertise. Dental provider credentialing application — Request to join our dental provider network. Provider update - Email this form to Premera with new information or changes to your current practice or payment structure.

The federal No Surprises Act requires health plans to verify all provider directory data every 90 day. It also requires all providers and facilities submit this information to in-network plans. Unverified providers may be removed from our directory. Email us your completed documents. The credentialing process typically takes 30 days. 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. 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.

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