In keeping with our commitment of promoting continuous quality improvement for services provided to our members, Highmark has entered into an agreement with eviCore healthcare (eviCore) to implement a musculoskeletal (MSK) surgery and interventional pain management (IPM) services prior authorization program. Beginning Sept. 24, 2018, providers may request prior authorization for procedures or services scheduled for Oct. 1, 2018, and after. If a prior authorization is not requested for a procedure or service planned for Oct. 1, 2018, and later, the claim may be denied.
eviCore performs utilization management for MSK surgical procedures and IPM services for Highmark's fully insured Commercial, Medicare Advantage, and Affordable Care Act members. Highmark manages prior authorizations for MSK surgeries or IPM services for all other members according to the member's benefits.
The MSK and IPM services program includes prior authorization for non-emergent MSK surgeries, including inpatient and outpatient lumbar, cervical, and thoracic spinal surgeries, and hip, knee, and shoulder surgeries and related procedures. Prior authorizations are required for outpatient IPM services such as spinal injections, spinal denervations, and stimulators or pain pumps.
Learn More About the MSK Surgery and IPM Program
You can access eviCore's Highmark implementation site for the most current information at https://www.evicore.com/provider/clinical-guidelines. There you'll find eviCore's evidence-based clinical guidelines, a list of Current Procedural Terminology codes that require authorization through eviCore, and other important resources and recent announcements.
Other options available to you for updates about the MSK surgery and IPM services prior authorization program include the Plan Central page of NaviNet and future issues of Provider News.
Last updated on 12/30/2021