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Preauthorization Reminders and New Behavioral Health UM Requirements

Date:
August 30, 2022

As more of your Highmark Blue Shield of Northeastern New York patients move onto Highmark’s system, understanding key preauthorization differences for your legacy and Highmark system patients will help ensure faster processing time and reduced administrative burden.

Using NaviNet for Preauthorization Requests

For patients on Highmark’s system, preauthorization requests must be submitted through NaviNet. We will be following Highmark’s list of procedures/DME requiring authorization.

  • You can access this list any time by going to hnenybs.highmarkprc.com and clicking the “Requiring Authorization” tab at the top of the PRC homepage.

Please note: high-end imaging, cardiac imaging, and cardiac implantable devices will need to be submitted to NaviNet for Highmark system patients.

  • Requests for high-end imaging and radiation therapy services will continue to be sent to NIA Magellan for your legacy system patients for the remainder of 2022.

You can submit preauthorization requests and view pending requests by logging into your NaviNet account and clicking “Authorization Submission” or “Auth Inquiry and Reports” on the side menu of Plan Central (in NaviNet) under “Workflows for this Plan.”

  • For additional guidance on how to navigate through NaviNet, please review the NaviNet user guide here.      

New NYS Behavioral Health UM Criteria

Beginning September 1, 2022, the NYS Office of Mental Health will implement new preauthorization criteria for inpatient behavioral health services for adults and children. This change will be effective for BOTH your Highmark system and legacy system patients.

Under the new criteria, only your adult and pediatric patients with the following complexity triggers will require preauthorization for behavioral health admissions:

  • High utilization of psychiatric inpatient or emergency department (ED) services in the past year which includes:
    • Three (3) or more psychiatric inpatient hospitalizations over the past twelve (12) months
    • Four (4) or more psychiatric ED visits in the past twelve (12) months
      • OR any combination of four (4) or more psychiatric inpatient and/or psychiatric ED visits in the past twelve (12) months
    • Three (3) or more medical inpatient admissions within the past twelve (12) months
  • Inpatient psychiatric readmission within thirty (30) days of discharge from a psychiatric inpatient unit with a length of stay exceeding thirty (30) days

For additional information about preauthorization for legacy and Highmark system patients, including faxes and phone numbers, or to review how to tell which system your patient is on, please visit our Highmark Affiliation FAQs.

Your Patients: Which System?
Highmark PRC
List of Procedures/DME Requiring Authorization
NaviNet User Guide

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