Highmark offers a two-level internal appeals process. First-level appeals must be filed within 180 days of the denial. Second-level appeals are available within 60 days of the first-level decision. After exhausting internal appeals, request an external review through the state insurance department.
Days 1-180: First-level appeal filing window. Days 15-45: Highmark first-level review and decision. Days 1-60 after decision: Second-level appeal window. Days 15-45: Second-level review. After internal exhaustion: external review through state insurance department.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-11 | Medical necessity | Clinical documentation insufficient | Include peer-reviewed guidelines supporting necessity |
| CO-197 | Precertification absent | Auth not obtained | Include proof auth was obtained or emergency exception applies |
| CO-50 | Non-covered service | Service excluded from plan | Reference plan documents showing coverage |
First-level: Highmark responds within 30 days. Second-level: physician reviewer not involved in original decision. External review: binding decision by an independent reviewer. Pennsylvania providers: file with the PA Insurance Department. West Virginia and Delaware have similar external review processes.
Two internal levels. First-level must be filed within 180 days. Second-level within 60 days of the first-level decision. After both, you can request external review through your state's insurance department.
Industry-wide, 70-80% of appealed denials are overturned when supported by clinical documentation. Include detailed clinical notes, peer-reviewed guidelines, and a clear explanation of medical necessity.
Yes. For clinical denials (CO-11), request a peer-to-peer review within 10 business days of the denial. This allows the treating provider to discuss the case with a Highmark medical director before filing a formal appeal.
Altair tracks appeal deadlines and prepares documentation for Highmark denial appeals.