Skip to main content

Highmark Medical Policy Updates

Date:
September 22, 2022

Highmark’s monthly Medical Policy Update Newsletter will be available online on or before September 26. Changes included in the newsletter may impact your patients who have moved onto Highmark’s system. Policy updates will be effective December 26, 2022 and can be reviewed by clicking the link below:

Medical policies for Highmark system patients can be reviewed by clicking the link below:

Recent Articles

  • 2023 Medicare Advantage Drug Formulary and Pharmacy Prior Authorization Changes
    Beginning January 1, 2023, some of your Highmark Blue Shield of Northeastern New York (Highmark BSNENY) Medicare Advantage patients may be affected by changes to Highmark’s pharmacy drug formulary. In early December, please be on the lookout for letters detailing select formulary changes affecting your Medicare Advantage patients. Medication-related prior authorization requests will be submitted to and reviewed by our Utilization Management (UM) team. In this article, you can review 2023 formulary updates along with information about the Medicare Advantage pharmacy prior authorization review process as all Medicare Advantage members move onto Highmark’s system.
  • Enhancements to NaviNet Prior Authorization Experience
    We will begin rolling out enhancements to our utilization management (UM) tool through NaviNet on January 1, 2023. These enhancements are intended to streamline your experience by enabling faster reviews and greater transparency around the status of your authorization requests. Here, you can find tips for submitting NaviNet authorization requests on the new platform.
  • Prior Authorization Changes Postponed for Musculoskeletal Procedures and Pain Management, Molecular and Genomic Testing, and Radiation Oncology
    We are postponing the authorization requirement changes for some musculoskeletal (MSK) procedures and interventional pain management, molecular and genomic testing, and radiation oncology services that we announced last month. The requirement updates, which will be managed by eviCore, will not take effect until late Q1 or early Q2. Webinars will be scheduled to orient providers to the eviCore programs before they take effect.
  • Reimbursement Reduction for Cassette-Based X-Ray Imaging
    Effective February 27, 2023, the reduction applied to the reimbursement for X-ray services using computerized radiography cassette-based imaging (FY modifier) is increasing from 7% to 10% (3% additional reduction) for your Highmark Blue Shield of Northeastern New York commercial and Medicare Advantage patients. In this article, you can access the updated reimbursement policy.
  • Two Injectables to Require Prior Authorization Beginning March 1
    On March 1, 2023, two injectable drugs will require prior authorization. Here, you can view the codes as well as additional information about prior authorizations.

Working with Us

Additional Resources

We want to hear from you! Have a topic request for the next Blue Bulletin? Email us

Stay in Touch! Sign up to receive emails for provider news and information