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3/26/2024

New Authorization Requirements for Musculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine

Highmark Wholecare is transitioning the authorization program for Musculoskeletal/Pain Management, Diagnostic Imaging and Physical Medicine to HealthHelp effective 5/1/24.

April 30, 2024 will be the last day providers will submit authorization requests to NIA/Magellan. For questions or follow-ups regarding authorization requests submitted to NIA/Magellan prior to 5/1, providers should contact NIA/Magellan.

Effective 5/1/24 all requests for the following tests and procedures will go through HealthHelp, except services rendered for emergency level of care:

  • Musculoskeletal/Pain Management: Spine Surgery and Pain Management
  • Diagnostic Imaging: CT Scans, PET Scans, MRIs
  • Physical Medicine: Physical Therapy, Speech Therapy, Occupational Therapy

A list of procedure codes requiring authorization and the registration link for a training webinar can be found at www.healthhelp.com/HighmarkWholecare. The webinar will include a system demonstration with user experience insight on how to appropriately enter procedure requests, along with additional program information such as the Highmark Wholecare procedure code list, support tools and HealthHelp contact information.

The HealthHelp authorization process for these programs will involve collecting relevant clinical information from the ordering/treating physician’s office, reviewing this information alongside current evidence-based guidelines, and if necessary, providing physician-to-physician consultation on treatment and/or test appropriateness and patient safety. If the requested service does not meet evidence-based guidelines, a HealthHelp specialist will have a provider-to-provider conversation with the requesting physician to consider alternatives.

We encourage new users to set up a HealthHelp login now at www.healthhelp.com/HighmarkWholecare, so you can start requesting authorizations May 1.

How to request and obtain an authorization

Step 1: Requesting Authorization

The most efficient method for obtaining an authorization number is through the web. Please contact HealthHelp program support at 1-800-546-7092 if you need assistance with setting up web access.

Ordering providers can request an authorization using one of the following methods:

Step 2: Receiving Authorization

  • Web: If the ordering provider chooses to submit the request through the web, authorization will be available online to print.
  • Phone: If an ordering provider chooses to submit their request via phone, a HealthHelp client service representative will provide a verbal authorization for an approved request. A faxed confirmation will also be faxed to the ordering provider’s office.
  • Fax: If the ordering provider chooses to submit the request via fax, a faxed copy of the authorization will be sent to the fax number provided on the request submission form.

HealthHelp representatives are available Monday–Friday, from 8 a.m. to 6 p.m. Eastern Standard Time. After-hour requests may be submitted by fax or via web portal.

For a medically necessary request that requires immediate handling due to an unforeseen illness, injury or condition affecting the patient, a phone call to 888-265-0072 is the fastest way to process that urgent request. If you choose to fax the request, please ensure that legible contact information is included for the ordering provider/designee. It should also state how the provider may be reached within the next 24 hours, in case additional clinical information is needed to complete the review.

All urgent requests will be handled within the appropriate state-specific or federal program−mandated expedited time frames. HealthHelp strives to complete all expedited requests for review within 24 hours of the request’s receipt, unless a more stringent time frame is mandated by specific state regulations.

For questions or information regarding general policy and procedures, contact a Highmark Wholecare provider representative at: Medicaid 1-800-392-1147, Medicare Assured 1-800-685-5209. Representatives are available 8 a.m. to 4:30 p.m., Monday - Friday. TTY users call 711.

Health benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the Blue Cross blue Shield Association ("Highmark Wholecare").
HealthHelp is a separate company that offers education and guidance from specialists in sleep, cardiology, radiation oncology, musculoskeletal, diagnostic imaging, and physical medicine for Highmark Wholecare.
NIA/Magellan is a separate company that administers prior authorization for certain services for Highmark Wholecare.
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The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.