Important Reminder: Provider Appeal Form for Fax and Mail Submissions

When submitting a post-service appeal by fax or mail, the Provider Appeals Form must be completed. Effective August 1, 2026, failure to complete and submit will result in the cancellation of your appeal due to insufficient information.

When you submit a post-service appeal through the NaviNet® Provider Portal, you will be prompted to complete this form within the portal. Please note, this form is only for post-service appeals, including reconsiderations of claim denials, retrospective reviews, and denied services. This form should not be used for member appeals, pre-service appeals, payment disputes, or resubmissions of corrected claims, which must be submitted to the Member Appeals Department or Claims Department, respectively.

As a reminder, if you disagree with a denial and wish to formally dispute the decision, you have several options for submitting a post-service appeal:

1.    Our Provider Portal, via NaviNet® (preferred method)

2.    Fax: 412-255-4503

3.    Mail: Highmark Wholecare

Attn: Provider Appeals

P.O. Box 890034

Camp Hill, PA 17089

To ensure timely processing and review, your appeal request must include:

• A Provider Appeal Form. All sections of the form must be completed.
• A written explanation of the appeal. Ensure you clearly state the reason for the appeal.
• Claim Number(s) being appealed.
• Date of service being appealed.
• Code(s) being appealed.
• Complete and relevant supporting clinical documentation.
• Return mailing address. Provide a complete and accurate address for the appeal decision letter.
• Timely filing limits apply.

NaviNet is a registered trademark of NaviNet, Inc., which is an independent company that provides a secure, web-based portal between providers and health care insurance companies.