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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.

Recent Articles

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    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.

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