Highmark’s peer-to-peer review process for prior authorization requests for Medicare Advantage members is no longer available as of Sept. 12, 2017.
The peer-to-peer conversation offered providers the opportunity to discuss a pending adverse determination of an authorization request for medications or medical services with another peer designee from Highmark before Highmark made a final decision. Elimination of the Medicare Advantage peer-to-peer review process benefits the member and the provider by resulting in a more timely and efficient processing of authorization requests.
With notification of a denial decision, providers and members continue to be informed of their appeal rights and procedures. The denial letter includes instructions on how a provider or member can request a Medicare Advantage appeal. The appeal will provide an opportunity for review of the initial determination and any additional documentation provided to support the request.
To ensure a thorough initial review of your authorization requests for medications or medical services for your Medicare Advantage patients, please be sure to:
