CommercialPrior AuthHigh impact
Highmark Expanding our prior authorization requirements
Blue Cross Blue Shield of Rhode Island·Physician / Facility
Effective date
Nov 1, 2020
We identified it
Jun 19, 2026
Summary
Effective November 1, 2020, Highmark is expanding prior authorization requirements to include outpatient services provided by out-of-area providers who participate with their local Blue Plan. Previously, only non-contracted providers required prior auth, but now all out-of-area providers must obtain prior authorization regardless of their contract status with local Blue plans.
Action Required
Immediately: Billing team must verify prior authorization for ALL outpatient services when Highmark members receive care from out-of-area providers, regardless of whether the provider is contracted with the local Blue plan. Update workflow to contact Highmark in advance of services using the number on member ID cards or submit authorization requests through NaviNet portal. Claims without proper authorization will be rejected.