In February of 2019, the West Virginia legislature passed West Virginia House Bill 2351, which impacts the prior authorization process for healthcare providers rendering services for certain West Virginia insureds.
In compliance with this legislation, beginning January 1, 2020 Highmark has:
A Prior Authorization Episode of Care is a grouping of outpatient services requiring prior authorization that generally follow a pre-identified trigger code. By requesting a Prior Authorization Episode of Care, outpatient services which would typically require separate authorization requests will be included (approved) if the initial trigger procedure is approved.
Be aware that the provider must know the performing provider information for each service within the prior authorization episode of care at the time the request is made. Authorization review for benefit eligibility and criteria for medical necessity and appropriateness will be done on the outpatient trigger code identified for each episode.
The outpatient Prior Authorization Episodes of Care include:
To request an outpatient prior authorization episode of care, please call the Utilization Management MSK Dedicated Team at 1-800-452-8507 and select option 4.