Highmark operates Blue Cross Blue Shield plans in Pennsylvania, West Virginia, and Delaware. The most common denial codes are CO-197 (no prior auth), CO-29 (timely filing), CO-16 (claim mismatch), and CO-45 (fee schedule). Highmark allows appeals within 180 days of the denial date.
Day 1: Claim denied. Days 1-3: Review EOB and denial code. Days 4-7: Gather documentation. Days 8-14: Submit corrected claim or appeal. Days 15-45: Highmark review. Day 46: Decision issued. Appeal deadline: 180 days from denial date.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | PA not obtained or expired | Submit PA 10+ days before service |
| CO-29 | Timely filing | Filed after 180-day deadline | Submit within 90 days for margin |
| CO-16 | Claim mismatch | Billed data differs from auth | Match all fields to authorization |
| CO-45 | Fee schedule exceeded | Billed above contracted rate | Reference Highmark contract rates |
Submit appeals within 180 days of the denial date. Use the Highmark NaviNet portal or mail to the address on the EOB. Include the denial notice, original claim, clinical documentation, and a provider letter. Highmark responds within 30 days for standard appeals.
Highmark uses NaviNet (navinet.net) as its primary provider portal. Log in to check claim status, view EOBs, submit prior auth requests, and file appeals.
Clean electronic claims: 15-20 business days. Paper claims: 30 business days. Claims requiring manual review may take up to 45 days.
Standard appeals rarely succeed for timely filing. You can file an exception request with proof of extraordinary circumstances: system outages, retroactive eligibility, or Highmark processing errors. Include documentation.
Altair flags Highmark denial risks before submission and tracks appeal deadlines automatically.