Highmark processes standard prior authorization requests within 15 calendar days. Urgent or expedited requests receive decisions within 72 hours. Medicare Advantage plans (Freedom Blue, Community Blue) follow CMS timelines: 7 days standard, 72 hours expedited.
Day 1: Submit PA via NaviNet with complete clinical documentation. Days 2-3: Completeness review. Days 4-15: Clinical determination (commercial). Days 4-7: Clinical determination (Medicare Advantage). If approved: auth number issued, valid 60-90 days. If denied: written notice with appeal instructions.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | PA not obtained | Submit PA 10+ days before service |
| CO-11 | Medical necessity | Insufficient documentation | Include detailed clinical notes |
| CO-50 | Non-covered service | Service outside plan benefits | Verify coverage before PA request |
Appeal denied authorizations within 180 days. For Medicare Advantage: request reconsideration within 60 days. Peer-to-peer reviews available within 10 business days of denial for clinical decisions.
15 calendar days for commercial plans. 7 calendar days for Medicare Advantage plans. The clock starts when Highmark receives a complete request with all required clinical documentation.
Yes, if the standard timeline could jeopardize the patient's health. Request expedited status at submission. Highmark must decide within 72 hours. If denied expedited status, the request reverts to standard timeline.
For Medicare Advantage plans, failure to respond within CMS deadlines may be treated as an approval. For commercial plans, contact Highmark provider services to escalate.
Altair tracks Highmark authorization timelines and alerts you before deadlines pass.