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Highmark is committed to working with health care providers to assure that our members, your patients, receive high-quality, medically necessary care in the most appropriate setting. Although there is no substitute for a physician’s professional opinion, the reality of today’s health care market is that in some instances, nationally accepted evidence-based guidelines are not followed, resulting in inappropriate or unnecessary care delivery.
Ensuring patients receive appropriate care based on well-established, evidence-based clinical guidelines will result in better outcomes, better experiences, and lower costs for our clients and our members. At the same time, Highmark is committed to trying to reduce unnecessary barriers to care and streamlining the patient experience.
In line with this approach, as announced in a Special eBulletin 
dated and posted on July 16, 2018, we are making updates to our prior authorization program to verify that the elective or planned care our members receive is medically necessary, appropriate, and performed in the optimal setting. In accordance with evidence-based guidelines, we are adding additional procedures to our prior authorization list.
Simultaneously, to reduce the administrative burden on our network providers for less complex cases, and to safeguard timely care and a better patient experience, we are removing other procedures from our prior authorization list.
In addition, 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 to implement a musculoskeletal (MSK) surgery and interventional pain management (IPM) services program. The new program incorporates a comprehensive clinical review, including predictive intelligence, clinical decision support, and peer-to-peer discussions. This approach confirms our members receive only medically necessary and appropriate MSK surgical and IPM services in the least intensive setting to promote the best outcomes.
The eviCore MSK surgery and IPM program and prior authorization changes will go into effect on Oct. 1, 2018.
We appreciate your support and the high-quality, cost-effective care you provide our members, your patients. We look forward to your continued assistance in ensuring that Highmark members receive appropriate, medically necessary services in a quality, clinically appropriate fashion.
Watch for detailed information on the Highmark Provider Resource Center for everything you’ll need to know. You’ll find the new MSK/IPM page under Care Management Programs.
