Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program

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. 

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

eviCore's website

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.

Educational Materials/Communications

• Frequently Asked Questions for Highmark Providers
• Prior Authorization Quick Reference Guide
• How to Enter Multiple Procedure Codes
• Prior Authorization Provider Orientation
  • Presentation

Other options available to you for updates about the MSK surgery and IPM services prior authorization program include the online provider portal(s) and future issues of Provider News.