Highmark Blue Shield (BS) is delaying the prior authorization requirement for outpatient physical medicine services until April 1, 2024. At that time, these changes — which impact Commercial Plans only — will include authorization requirements and medical policies.

Prior authorization will be required for the following outpatient physical medicine services, starting April 1, 2024:

• Physical therapy
• Occupational therapy
• Chiropractic
• Home health

The delay will allow providers time to transition to our new provider portal, Availity Essentials^®, and become familiar with the Predictal™ Auth Automation Hub and Helion Arc — our electronic authorization solutions which are seamlessly integrated within Availity. The Auth Automation Hub and Helion Arc enable offices to submit, update, and query these authorization requests. They feature an easy-to-use interface that allows for faster reviews and greater transparency around the status of authorization requests.

Speech Therapy

Since April 1, 2023, prior authorization has been required for Commercial Plans for speech therapy (ST) in the Highmark BS service area. For more information, see the Provider News article from earlier this year.

Why Is Highmark Making This Change?

The goal of Highmark’s prior authorization process is to ensure members are receiving appropriate services and lowering their total cost of care. Highmark continues to align our prior authorization guidelines across all its markets to ensure consistency in care among our membership. As part of ongoing evaluation of our guidelines, they are adapted periodically based on clinically evidenced criteria, safety and approval ratings indicating ongoing compliance.

Training

To help providers with these changes, Highmark will offer both live and on-demand training. Training dates and information will be posted on the Provider Resource Center and be included in upcoming issues of Provider News, closer to the April 1, 2024, implementation date.

Resources

For additional resources on the Provider Resource Center, go to AUTHORIZATIONS on the left menu, click on Procedures/Service Requiring Prior Authorization. If you need assistance regarding electronic authorization workflows, you can email us at ElecAuthSubmit@highmark.com.