Important Highmark Reminders: Utilization Review, Patient Notification, and More

Appropriate Utilization Decision Making

Highmark makes utilization review decisions based only on the necessity and appropriateness of care, service, and the existence of coverage. In addition, Highmark does not reward practitioners, providers, Highmark employees, or other individuals conducting utilization review for issuing denials of coverage or service, nor does the company provide any financial incentives to utilization review decision-makers to encourage denials of coverage.

Request for Criteria

Highmark uses resources such as nationally recognized clinical review criteria, medical policy, and Medicare guidelines in determining whether a requested procedure, therapy, medication, or piece of equipment meets the requirements of medical necessity and appropriateness. This is being done to ensure the delivery of consistent and medically appropriate health care for our members.

If a primary care physician (PCP) or specialist requests a service that a clinician in Utilization Management is unable to approve based on criteria/guidelines, the clinician will refer the request to a Highmark Physician Reviewer. The reviewer may contact the PCP or specialist to discuss the request or to obtain additional clinical information.

A decision is made after all the clinical information has been reviewed.

At any time, the PCP or specialist may request a copy of the criteria/guidelines used in making health care decisions by calling the telephone number identified on the determination letter or the telephone number of the back of the member identification card. Details regarding criteria/guidelines requests are also available in the following section of the Highmark Provider Manual's Chapter 5, Unit 1 – 5.1 Criteria for Medical Management Decisions.

Patient Notification of Approvals, Denials

All network providers are expected to notify their patients who are Highmark members of both approval and denial-of-coverage decisions as soon as possible upon their office receiving notification of the decision from Highmark or a delegated entity of Highmark.

Peer-to-Peer Conversations: Availability of Physicians, Behavioral Health Practitioners, and Pharmacist Reviewers*

Highmark provides you with an opportunity to discuss utilization review denial decisions with a clinical peer reviewer following notification of a denial determination. Clinical peer reviewers are licensed and board-certified physicians, licensed behavioral health care practitioners, and licensed pharmacists who are available to discuss review determinations during normal business hours.

Your call will be connected directly to the peer reviewer involved in the initial review determination. If the original peer reviewer isn’t available when you call, another clinical peer will be made available to discuss the denial determination within one business day of your request. To request a peer-to-peer conversation, you may call the appropriate number listed in the chart below.

*IMPORTANT NOTE: The peer-to-peer review process is no longer available for Medicare Advantage members. See the 5.5 Peer-to Peer Conversation section of the Highmark Provider Manual's Chapter 5, Unit 5.

Provider Accessibility Expectations

To stay healthy, our members must be able to see their physicians when needed. Highmark has set forth specific time frame standards in which network providers should respond to member needs based on symptoms.

Physicians are encouraged to see members with scheduled appointments within 15 minutes of their scheduled appointment time. A reasonable attempt should be made to notify members of delays.

More specific information on Highmark’s time frame requirements is available in the Highmark Provider Manual's Chapter 1, Unit 4: Highmark Member Information.