Highmark wholecare prior authorization

When considering medications from a class included on the Statewide PDL for MA beneficiaries, providers should try to utilize drugs that are designated as preferred. Drugs designated as non-preferred on the Statewide PDL remain available to Highmark wholecare prior authorization beneficiaries when determined to be medically necessary through the prior authorization process. The Statewide PDL is a list of medications that are grouped into therapeutic classes based on how the drugs work or the disease states they are intended to treat.

Services centered around you. The services you need to keep your employees healthy. At MedExpress, we understand that accidents and illness can happen anytime. See the information below to help plan your visit to your MedExpress neighborhood medical center. Some exclusions may apply for select insurance plans. We strive to provide you with the best possible experience, including the insurance process. While we accept most major insurance, in-network status may vary by state and center.

Highmark wholecare prior authorization

This information will be used for purposes of performing services to, or on behalf of, our enterprise customers and prospective customers as part of and in relation to matters regarding our provider, health plan, and subsidiary enterprise care delivery, administration and operations. Your email address and phone number may be used to contact you. All reasonably appropriate measures will be taken to prevent disclosure of your Personal Data beyond the scope provided directly or indirectly herein or as may be reasonably inferred from the content contained in this notice or the website. Your Personal Data will be disclosed to appropriate personnel for purposes of performing services to, or on behalf of, our enterprise customers and prospective customers as part of and in relation to matters regarding our provider, health plan, and subsidiary enterprise care delivery, administration and operations. Notwithstanding the above disclosures, we will disclose the Personal Data we collect from you under the following circumstances:. We use third-party service providers to process Personal Data, including, without limitation, for information storage and other similar purposes. These services providers are located in the United States. These service providers will be bound by sufficient guarantees to implement appropriate technical and organizational measures in such a matter that their processing will meet the requirements of applicable law. Your Personal Data will remain on file for: any period required by applicable law; and, to the extent necessary for any purpose s provided directly or indirectly herein or as may be reasonably inferred from the content contained in this notice or the website, but no longer than permitted by applicable law. After that, all Personal Data will be deleted or the documents with such data will be anonymized. If you have questions regarding how we process your Personal Data and what we store about you, please contact PrivacyInternational HighmarkHealth. By agreeing to the terms and conditions set out in this Data Protection Statement, and by providing us with your Personal Data, you consent to the collection, use and disclosure of any information you provide in accordance with the above purposes and this Data Protection Statement. You also explicitly consent to the automated decision making by us, which may include the processing of your health data, to the extent that it is necessary to process your health claim swiftly and efficiently. Notes: This consent is given voluntarily and can be revoked at any time in writing by sending an email to PrivacyInternational HighmarkHealth. If you are not satisfied with our data processing you have the right to lodge a complaint to the data protection authority in your country of residence.

Telephone: For inquiries that cannot be handled via the online provider portal, call the appropriate Clinical Services numberwhich can be found here. Requiring Authorization. Unfortunately, there are no MedExpress centers in this area.

Introducing a new provider resource experience that simplifies getting you the information you need, when you need it. Your feedback is appreciated as we work to complete the experience. The authorization is typically obtained by the ordering provider. Some authorization requirements vary by member contract. This information should not be relied on as authorization for health care services and is not a guarantee of payment. Benefit plans vary widely and are subject to change based on the contract effective dates.

As a provider, you have access to a wide variety of tools and resources designed to help you deliver better service. If you haven't already done so, follow these simple steps to get the most out of your Highmark Wholecare partnership. Join our network by completing this form. Login to the provider portal. Review and download Medicare Assured and Medicaid Policies. Check out the Provider Newsletter. Highmark Wholecare participating providers have access to our Provider Authorization Portal. Simply access the portal by clicking here.

Highmark wholecare prior authorization

Starting January 1, , Highmark Wholecare will no longer require prior authorization for over services. A listing of the affected Medicare and Medicaid services can be found on our website here. We value your continued partnership and hope this update will help add administrative efficiencies. If you have any questions, please reach out to your Provider Account Liaison. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. You're being redirected to the CMS search site. Quick Links: Manuals. Medicare Provider Manual.

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Llame al TTY Authorization Status. The Statewide PDL is not the same as the formularies that are commonly used by commercial insurers. Back to Table of Contents. Some exclusions may apply for select insurance plans. To verify that your insurance is in-network, please check the listing below. Get my kit. Notwithstanding the above disclosures, we will disclose the Personal Data we collect from you under the following circumstances:. Invalid format. Please enable scripts and reload this page. Contact Us. October 1 — March 31, 8 a.

Introducing a new provider resource experience that simplifies getting you the information you need, when you need it. Your feedback is appreciated as we work to complete the experience.

Utilization management of physical medicine services is now managed by Highmark. The Statewide PDL is therapeutically based. Highmark launched the Predictal Auth Automation Hub utilization management tool that allows offices to submit, update, and inquire on authorization requests. For your convenience, MedExpress offers a discount to those patients who choose to pay in full for their visit at the time of service. The Statewide PDL will be updated annually, but that will not preclude beneficiaries from getting new drugs that come to market as long as they meet CMS criteria for a Medicaid covered drug. By providing your email you will receive confirmation of your request as well as other helpful information from Highmark Wholecare. Back to Table of Contents. Additional Resource: MCG Guidelines Product Acronym List Fax: If you are unable to use the online provider portal, you may also fax your authorization requests to one of the following departments. You are now leaving a Highmark website. The associated preauthorization forms can be found here.