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Highmark Denial Appeals Process and Deadlines

Overview

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.

Key Requirements

  1. First-level appeal: file within 180 days of the denial date.
  2. Submit via NaviNet portal or mail to the appeals address on the EOB.
  3. Include: denial notice, claim, clinical documentation, and provider letter.
  4. Second-level appeal: file within 60 days of first-level decision.
  5. External review: contact the PA Insurance Department (or WV/DE equivalent) after internal appeals.

Timeline

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.

Common Denials

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

Appeals

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.

FAQ

How many levels of appeal does Highmark have?

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.

What is the success rate for Highmark appeals?

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.

Can I request a peer-to-peer review with Highmark?

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.

Prevent These Denials

Altair tracks appeal deadlines and prepares documentation for Highmark denial appeals.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.
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