Overview
Highmark publishes medical policies and coverage guidelines on the NaviNet portal. Coverage varies by plan type (commercial, Medicare Advantage, Medicaid managed care). Always verify the member's specific plan benefits before billing.
Key Requirements
- Access coverage policies through NaviNet at navinet.net.
- Medical policies are searchable by CPT code, ICD-10, or keyword.
- Coverage varies by plan: commercial HMO/PPO, Medicare Advantage (Freedom Blue, Community Blue), and Medicaid (Gateway Health).
- Verify real-time eligibility through NaviNet or Availity.
- Prior auth requirements listed in the Highmark PA lookup tool on NaviNet.
Timeline
Before scheduling: Look up coverage policy for the planned service. Verify eligibility and benefits. Check PA requirements. Day of service: Re-verify eligibility. After service: Submit claim with verified information.
Common Denials
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-50 | Non-covered service | Service excluded from plan | Verify coverage policy before scheduling |
| CO-167 | Diagnosis not covered | ICD-10 not in coverage policy | Check diagnosis coverage in medical policy |
| CO-197 | No prior auth | Auth required but not obtained | Check PA lookup tool before scheduling |
Appeals
If you disagree with a coverage determination, file an appeal within 180 days. Include the Highmark medical policy reference showing why the service should be covered under the member's plan.
FAQ
Where do I find Highmark medical policies?
Log into NaviNet and navigate to Medical Policy. Search by CPT code, ICD-10 code, or keyword. Policies are updated quarterly.
How do I check if a service requires prior auth with Highmark?
Use the PA Lookup tool on NaviNet. Enter the CPT code and plan type. The tool shows whether PA is required and what clinical documentation is needed.
Does Highmark coverage differ between PA, WV, and DE?
Yes. While Highmark operates in all three states, coverage policies can differ based on state regulations and plan types offered in each state. Always check the member's specific plan.
Prevent These Denials
Altair checks Highmark coverage policies and PA requirements automatically before every claim.