Effective August 1, 2021, Highmark is expanding its Advanced Imaging and Cardiology Services program (managed by eviCore) to include Out-Of-Area (OOA)1 and Out-Of-Network (OON)2 providers/services serving Highmark members enrolled in its fully insured Commercial, Medicare Advantage, Affordable Care Act (ACA) plans, and members of select self-insured (Administrative Services Only) groups.
Highmark’s prior authorization requirements ensure that our members receive the most appropriate care delivery in alignment with nationally accepted evidence-based guidelines.
The program includes prior authorization for elective or non-emergency outpatient radiology or cardiac imaging services (Prior authorization does not apply to services that are performed in the emergency room or during an inpatient stay.) Services include:
For more information on this change and for guidance on submitting a prior authorization for OOA or OON providers/services, see the AUTHORIZATIONS SOON REQUIRED FOR OUTOF-AREA AND OUT-OF-NETWORK ADVANCED IMAGING AND CARDIOLOGY SERVICES eBulletin published on the Provider Resource Center.
1OOA services are those performed by a provider outside of the Highmark health plan footprint of Pennsylvania, Delaware, and West Virginia and who is participating with their local Blue Plan.
2OON services are those performed by a provider who is not contracted with Highmark or any other blue plan or is excluded from certain benefit plans. These services can occur within Highmark’s footprint or OOA.