Provider Resource Center (2024)

FAQs

What is the provider line for Highmark of Pennsylvania? ›

Provider Service Center at: Western Region: 1-800-547-3627, option 2. Central Region: 1-800-345-3805, option 3. Hours are from 9:00 a.m. to 4:30 p.m., Monday through Friday. What Region Am I?

In 2021, Highmark Health acquired full ownership of Gateway Health, after previously holding a 50 percent ownership interest. This paved the way for the organization to become a Blue Cross Blue Shield licensee.

You can verify a patient's eligibility with Highmark Blue Shield via several automated inquiry mechanisms. OASIS, our automated voice response system using your touch tone telephone; InfoFax, our service that responds to inquiries via your fax machine; or NaviNet, our Internet-based inquiry system.

Highmark requires authorization of certain services, procedures, and/or Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) prior to performing the procedure or service.

Highmark members with broad-network commercial or Medicare Advantage plans (which is the majority of Highmark members) have full, in-network access to UPMC hospitals, doctors, and services. Highmark members with narrow-network plans have some limited in-network access to UPMC.

Highmark Inc. is an independent licensee of the Blue Cross Blue Shield Association.

Gateway Health plans will soon be Highmark Wholecare – same access to doctors, same commitment to care and whole-person approach to health. All that's changing is the plan names. You can learn more about the transition to Highmark Wholecare, effective January 1, 2022, by visiting their website.

For 2022, Highmark Wholecare Medicare Assured received a 4.5 star rating overall for both Diamond and Ruby plans.

Health-related insurance

Highmark is also affiliated with Allegheny Health Network®. Allegheny Health Network is the parent company of a unified healthcare system dedicated to providing affordable, exceptional care to people in the communities it serves.

Availity Essentials is now Highmark's* provider portal

Starting in late 2023, Highmark began moving their secure provider portals to Availity® to give you an enhanced provider portal, where you can: Check eligibility and benefits. Determine if an authorization is required. Check claim status.

What states is Highmark in? ›

and its Blue-branded affiliates proudly cover the insurance needs of approximately 7 million members in Pennsylvania, Delaware, New York and West Virginia. Its diversified businesses serve group customer and individual needs across the United States through dental insurance and other related businesses.

Patient eligibility and benefits verification is the process by which practices confirm information such as coverage, copayments, deductibles, and coinsurance with a patient's insurance company.

The prior authorization process begins when a service prescribed by a patient's physician is not covered by their health insurance plan. Communication between the physician's office and the insurance company is necessary to handle the prior authorization.

If a provider's office submits a wrong billing code, misspells a name or makes another clerical error, this can result in a denied PA request. This is common for procedures like cosmetic surgery or treatments not approved by the FDA.

If your provider doesn't ask for prior authorization when required, the claim will be denied. The provider CANNOT bill you for the treatment if they did not get prior authorization.

For a list of network providers, see www.highmarkbcbs.com or call 1-866-283-4995. This plan uses a provider network.

Allegheny Health Network was formed to act as the parent company to the WPAHS hospitals and its affiliate hospitals. Highmark Health today serves as the ultimate parent of AHN.