We value your participation with Highmark and the quality service you provide to our members. We have made significant investments in our self-service tools to reduce administrative burden, improve office workflows, and simplify complex transactions — allowing you and your staff to focus on delivering care to our members.
As a result of this evolution, Highmark requires providers to utilize our enhanced self-service tools to obtain the fastest resolution to many common issues and tasks. This allows our Provider Service advocates to assist with more complex issues and your staff avoid unnecessary hold times on the telephone.
- Highmark’s Provider Resource Center (PRC): You are here! The PRC is the main hub for you and your staff to review important information and tools, such as EFT registration, policies, procedures, and the Provider Manual.
- Availity Essentials, Highmark’s Provider Portal: The primary method to submit transactions to Highmark and access reports:
- Value Insights Center (Value-Based Program Reporting Tool)
- Credentialing (Initiate Application, Submit Change, Review Status)
- Eligibility and Benefits Check
- Authorization Submission
- Claim Submissions/ Investigations – The use of Availity to check claim status and submit a claim investigation is required.
- Interactive Voice Response (IVR) System: The Provider Service Center offers options for you to access information, such as claim status or member benefits, without a live agent.
Our wide range of self-service tools available 24/7. Use the below chart as a reference if you are unsure of where to start. Download here.
Topic(s)
|
Inquiry Examples
|
1st Level |
2nd Level |
Self Service
(required for many transactions)
|
Provider or Clinical Service
|
Authorization Appeals / Grievances
|
•Confirm status of retrospective reviews and appeals
•Appeal sent but not received
•Disputing decision
|
Availity: Status check for Retrospective Reviews & Appeals
Peer-to-Peer: (866) 634-6468 to schedule
|
Contact Regional Provider Service: Contact Page
|
Authorization & Pharmacy
|
•Urgent or non-urgent prior authorization requests
•Post-acute discharge
•Check authorization status
|
Availity: Submit authorization, check status or make changes
Portal Submission Guides: Inpatient Authorization Submission (Both Urgent and Non-Urgent);
Outpatient Authorization Submission
|
Contact Clinical Services or Pharmacy: Contact Page (If services are within 72 hours, Post-Acute or Pharmacy related)
|
Claims
|
•Claim didn’t process correctly or according to expectation
•Adjustment has not been completed timely
•Submitted adjustment bill and claim has been rejected as duplicate rather than adjustment
•Status of submitted claim
|
Availity: Claims inquiries/direct messaging (including follow-up to an initial inquiry)
Interactive Voice Response: Can be used to check claims status (Contact Page)
|
Contracting
|
•Contract payment was made incorrectly
|
Contact Regional Provider Service: Contact Page
|
Eligibility & Benefits
|
•View member ID card
•Member cost share
•Deductible renewals
•New benefit year information
|
Availity: Benefits and eligibility check
|
Contact Regional Provider Service: Contact Page
|
Medical Policy
|
•Medical necessity and coverage guidelines
•Coding guidance
|
Provider Resource Center: Commercial Medical Policy Search Tool Delaware; New York; Pennsylvania, West Virginia
(Highmark adheres to the Centers for Medicare and Medicaid Services coverage determinations for Medicare Advantage membership.)
|
Contact Regional Provider Service: Contact Page
|
Remittance
|
•Didn’t receive file for claims payment
•Don’t understand file
•Didn’t get payment file (EFT)
|
NY
|
Highmark EDI: (800) 992-0246
Highmark EDI: Satisfaction Survey
|
Contact Regional Provider Service: Contact Page
|
DE, PA, WV
|
ECHO Support: (800) 890-4124
ECHO: User guide
|
|
Last updated on 5/8/2024 11:17:11 AM