Authorizations Required for Out-Of-Area and Out-Of-Network Advanced Imaging and Cardiology Services

to come...

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:

Radiology Cardiac Imaging
  • Magnetic resonance imaging (MRI)
  • Magnetic resonance angiograms (MRAs)
  • Positron emission tomography (PET) scans
  • Positron emission tomography – computed tomography (PET-CT)
  • Computerized tomography (CT) scans
  • Computed tomography angiography (CTA) scans
  • Nuclear medicine
  • Cardiac CT
  • Cardiac MRI
  • Diagnostic heart catheterization
  • Myocardial perfusion imaging (SPECT and PET)
  • Nuclear cardiac imaging
  • Stress echocardiogram
  • Stress testing
  • Transesophageal echocardiogram
  • Transthoracic echocardiogram

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.