Changes to 24/7 Coverage Requirements for Providers

Effective Jan. 1, 2027, the verification of 24/7 coverage will no longer be a validated component during the credentialing and recredentialing processes. However, 24/7 after-hours coverage remains a critical requirement for all providers, with the exceptions noted below.

The following specialties are exempt from the 24/7 after-hours coverage requirement:

• Audiologists
• Certified Diabetic Educators (CDE)
• Dermatopathologists
• Dieticians/Nutritionists
• Massage Therapists
• Non-Hospital-Based Oral and Maxillofacial Pathologists
• Non-Hospital-Based Pathologists
• Occupational Therapists
• Physical Therapists
• Psychologists who only perform neuropsychological testing or psychological evaluations
• Read-only Practitioners
• Speech/Language Pathologists

New Verification Process for 24/7 Coverage

Starting in January 2027, a new process will be implemented to verify compliance with the 24/7 after-hours coverage requirement. A random sample of 100 practices will be contacted monthly to confirm their coverage.

Acceptable Methods for Meeting 24/7 After-Hours Coverage

Providers can fulfill this contractual requirement through several methods:

• After-Hours Message via Text/Email – Sending an after-hours message via text or email, with the provider responding to the member within 60 minutes.
• Answering Service/Pager/Direct Telephone Access – Utilizing an answering service, pager, or direct telephone access allowing the practitioner or their designated colleague of the same or similar specialty to be directly reached.
• Answering Machine with Call Back Number – Utilizing an answering machine that includes a call-back number, enabling direct access to the practitioner or their designated colleague of the same or similar specialty.
• Hospital Emergency Room (ER) or Operator Referral – Directing members to contact a hospital ER or operator after hours. The ER staff or operator can then contact the provider for triage, appropriate treatment, or referral services.
• Office Manager or Nursing Staff Triage – An Office Manager or nursing staff triages calls 24/7 and contacts the on-call provider as necessary.
• Provider-Supplied Cell Phone – Providing members with a direct cell phone number for 24/7 access.

Additional Options for Allied Behavioral Health Providers

These practitioners have two additional options for 24/7 after-hours coverage:

• Crisis Center Referral – In addition to the above options, Behavioral Health (BH) providers may direct members to call a Crisis Center. This is acceptable provided the center can directly contact the practitioner for any questions or concerns.
• Individualized Crisis Plans – Developing individualized crisis plans based on member/patient needs and diagnoses, which include a clear action plan for after-hours situations.

Allied behavioral health providers include Licensed Professional Counselors, Licensed Mental Health Counselors, Licensed Clinical Social Workers (WV only), Licensed Psychoanalysts (NY only), Behavior Analysts/Behavioral Specialists, Psychologists, and Marriage and Family Therapists.

Important: Verification Outreach and Appeal Process

If 24/7 coverage cannot be verified during initial outreach, additional attempts will be made to confirm compliance. This outreach may involve education, clarification, or notification of termination from network participation. Practices receiving a notice of termination will retain the right to appeal the decision.

Further Information

Prior to Jan. 1, 2027, the following sections in the Highmark Provider Manual will be updated to reflect these changes to 24/7 coverage:

• 3.1 Introduction to Network Participation
• 3.2 Introduction to Credentialing
• 3.2 Reconsiderations and Appeals
• 4.1 PCP and Medical Specialist Accessibility Expectations
• 4.2 Accessibility Expectations for Behavioral Health