MSK Authorization Transition on May 1; Your Questions Answered

As previously communicated, Highmark will directly manage authorization requests for musculoskeletal (MSK) and interventional pain management (IPM) services, moving from eviCore, effective May 1, 2026.

To gain a better understanding of how the transition from eviCore to Highmark will work, see the information below.

• Authorization Submissions:
  • Prior to May 1 (any date of service): Processed by eviCore.
  • On or after May 1 (any date of service): Processed by Highmark.
• Existing Authorizations: eviCore current authorizations spanning past May 1 will be honored.
• Retrospective Authorization and Claim Review: Review of all retrospective auths and claims will be managed by Highmark, effective May 1.
• eviCore Runout Period (until June 30, 2026): eviCore will process site changes, peer-to-peer reviews (P2Ps), reconsiderations, and appeals for cases they previously decisioned until June 30, 2026.
  • Exception: Medicare Advantage and member appeals are managed by Highmark directly.

Site of Care Reminder

As part of the transition, more than 100 MSK surgical procedure codes are being added to Highmark’s site of care clinical review requirements, effective May 1. Read the full article here.