Retrospective Auth Requests Must Be Submitted Within Two Years

Effective Aug. 1, 2026, Highmark requires that all retrospective authorization requests be submitted within two years of the date of service.

The majority of retrospective authorization requests are currently submitted within six months of the date of service.

If the retrospective review is submitted after two years past the date of service, no payment will be made for the claim, and the network provider may not bill the member in accordance with their network participation agreement.

Prior Authorization Reminders

Authorization requests should be submitted at least 14 days in advance prior to a planned admission or service, when possible, or as soon as the intended admission or service is known.

For emergency (urgent, unplanned) admissions, the hospital is asked to obtain an authorization within 48 hours of the admission or as soon as the necessary clinical information is available.

Retrospective Review Submission

To request a retrospective review of an inpatient admission or an outpatient medical service provided without the appropriate authorization, the preferred method is to submit a request in Availity Essentials via the Authorizations and Referrals workflow.