How Will Highmark’s New Prior Authorization Program Impact Physicians and Patients?

Last Updated: Jan 15, 2019

MRIHighmark’s Advanced Imaging and Cardiology Services Program, which began on Jan. 1, 2019, requires that clinicians obtain prior authorization for a variety of services such as echocardiograms and nuclear imaging. The new program is being managed by eviCore healthcare (eviCore).

Physicians have expressed concerns about how new prior authorization requirements may affect patient care and office workflow. On Jan. 10, 2019, Highmark and eviCore leaders met with stakeholder groups – including the Pennsylvania Medical Society (PAMED), the Allegheny County Medical Society, the Pa. Chapter of the American College of Cardiology, and the Pittsburgh Business Group on Health – to discuss the program.

Highmark said the program was put in place because its utilization numbers were trending higher compared to benchmarks in markers such as Medicare, Medicaid, and other commercial plans.

Approximately 80 percent of approvals should occur within seconds, Highmark says. Practices that experience approval delays or other issues are encouraged to share their experiences with PAMED by contacting our Knowledge Center at 855-PAMED4U (855-726-3348) or PAMED will share your feedback with Highmark.

The stakeholder group will meet with Highmark again in six months to discuss how program implementation is working. PAMED will share any updates with our members.

More Details on the Advanced Imaging and Cardiology Services Program

Here’s a closer look at how the program works, including which Highmark members are affected and which imaging and cardiology procedures require prior authorization.

Keep in mind that the program applies to outpatient, non-emergent services. Highmark confirms that eviCore does not manage the prior authorization for advanced imaging or cardiology services that are performed during an inpatient stay, in an emergency room setting, or observation stay.

Affected Highmark Plan Holders
EviCore will manage the prior authorizations for advanced imaging and cardiology services for Highmark's fully insured Commercial, Children's Health Insurance Program (CHIP) of Pennsylvania, Medicare Advantage, and Affordable Care Act members, plus members of select self-insured (Administrative Services Only) groups. The Federal Employee Program is excluded from this program.

Physicians and practices should also be aware that some employer groups may choose to opt out of the program. You can use NaviNet to verify member benefits to determine whether prior authorization is required.

Privileging Applications for Providers
Providers can begin submitting privileging applications to eviCore for dates of service after Jan. 1, 2019. Additionally, providers whose privileges expire during the first quarter of 2019 will be given a three-month privileging extension. During the transition period, eviCore may take up to 20 days to complete a privileging request.

Procedures That Require Prior Authorization 
For the advanced imaging component, prior authorization is required for the following outpatient, non-emergent, elective advanced imaging services:

  • CT, CTA
  • MRA, MRI
  • Nuclear medicine

For the cardiology services component, prior authorization is required for the following outpatient, non-emergent, elective cardiology services:

  • Cardiac CT
  • Cardiac MRI
  • Diagnostic heart catheterization
  • Myocardial perfusion imaging (SPECT and PET)
  • Nuclear cardiac imaging
  • Stress echocardiogram
  • Transesophageal echocardiogram
  • Transthoracic echocardiogram

Highmark offers this list of codes that require prior authorization.

For more details on the Advanced Imaging and Cardiology Services program, you can access Highmark’s ebulletin here.

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  1. Mumtaz Momin | Jan 17, 2019

    Highmark's Authorization requirements for Pain Management effective 10/1/2018 has been nightmare. System has been very slow and unreliable, staff has to enter patient informtion and clinical information into Highmark' s Navinet portal, which then connects to Evicore, which is extetrmely slow, staff has to re-enter same information again into the Evicore system. Connections to Evicore site is not perfect so if you are unlucky and loose the communication  then repeat the whole thing again.  All of these changes have cost us significant time and money. Highmark also does not have consistent auth requirement for all its products. Providers are left to explain to the patient why his neighbor does not require auth  but he does. While all of these is costing providers in additional labor and money it is also adding extreme mental stress to medical providers and supporting staff.

    Mumtaz Momin

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