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Highmark Authorization Approval Timeline Guide

Overview

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.

Key Requirements

  1. Standard commercial PA: 15 calendar days.
  2. Urgent commercial PA: 72 hours.
  3. Medicare Advantage standard: 7 calendar days (CMS requirement).
  4. Medicare Advantage expedited: 72 hours (CMS requirement).
  5. Submit via NaviNet portal with clinical documentation.

Timeline

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.

Common Denials

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

Appeals

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.

FAQ

How long does Highmark take for standard prior auth?

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.

Can I get an expedited Highmark authorization?

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.

What happens if Highmark does not respond in time?

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.

Prevent These Denials

Altair tracks Highmark authorization timelines and alerts you before deadlines pass.

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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