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Utilization Management: Coverage and Denial Processes

Date:
September 22, 2022

Coverage Decisions Based on Appropriateness of Care

Medical necessity decisions are made on the appropriateness of care and services. Coverage decisions are based on the benefits and provisions contained in patients’ contracts. We do not reward or offer incentives to practitioners, providers, or staff members for issuing denials or for encouraging inappropriate under-utilization of care.

Discussing an Adverse Determination

Legacy System Patients

If you would like to discuss a denial decision based on medical necessity with our physician reviewers for a Highmark Blue Shield of Northeastern New York legacy system patient, please call 1-800-677-3086.

You can also discuss adverse determinations with our physician reviewers when you are notified of our determination. Criteria used by Utilization Management to render our decisions can be found here.

You may also request the criteria by calling the number above or by sending a written request to:

Highmark Blue Shield of Northeastern New York
Attn: Utilization Management
PO Box 80
Buffalo, NY 14240

Highmark System Patients

If you would like to discuss a denial decision based on medical necessity for your Highmark system patients, please call 1-844-946-6263.

You can also discuss adverse determinations with our physician reviewers when you are notified of our determination. Criteria used by Utilization Management to render our decisions can be found here. You may also request the criteria  by calling the number above or by sending a written request to:

Highmark Blue Shield of Northeastern New York
Attn: Utilization Management
PO Box 4208
Buffalo, NY 14240

For both your legacy and Highmark system patients, you may also obtain criteria in person at:

Highmark Blue Shield of Northeastern New York
40 Century Drive
Latham, NY 12110

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.

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