Care Management Programs

Advanced Imaging and Cardiology Services Program
Highmark partners with eviCore Healthcare (eviCore) for our Advanced Imaging and Cardiology Services Program. This program provides medical necessity review and authorization, where applicable, of select cardiac imaging and radiology services. The program incorporates a comprehensive, evidence-based clinical review including predictive intelligence, clinical decision support, and peer-to-peer discussions.

AIS Home Visit Program 
In collaboration with Aspire Health, the AIS Home Visit Program is focused on caring for our Medicare Advantage and ACA members who have a serious illness.

Laboratory Management Program
The resources contained on this page will assist providers in their understanding of the Laboratory Management Program.

Musculoskeletal Surgery And Interventional Pain Management Services Prior Auth Program
The MSK and IPM services program includes prior authorization for non-emergent MSK surgeries, including inpatient and outpatient lumbar, cervical, and thoracic spinal surgeries, and hip, knee, and shoulder surgeries and related procedures. Prior authorizations are required for outpatient IPM services such as spinal injections, spinal denervations, and stimulators or pain pumps.

Physical Medicine Management Program
The materials contained in this location will assist the provider in their understanding of the Physical Medicine Management Program.

Post-Acute Care Management For Medicare Advantage Members
Highmark has initiated a three-year partnership with naviHealth, a national post-acute care management company, to bring a personalized approach to support its Medicare Advantage members across Pennsylvania. According to patient needs, naviHealth will utilize decision-support technology and its post-acute analytics capabilities to coordinate long-term acute care, inpatient rehabilitation and skilled nursing facility utilization and will oversee proper care transitions to and from these facilities. Through a highly collaborative process, this partnership enables us to increase member satisfaction, lower readmission rates and improve clinical outcomes

Radiation Therapy Authorization Program
In an effort to help ensure that the radiation oncology therapy services provided to our members are consistent with nationally recognized clinical guidelines, Highmark has contracted with eviCore healthcare to provide medical necessity review and authorization where applicable for select radiation oncology therapy services.

Radiology Management Program
eviCore provides medical necessity review and authorization, where applicable, for select outpatient Cardiology and Radiation Therapy services for Highmark members. You can review eviCore's evidence-based clinical guidelines by accessing eviCore's Highmark implementation site at evicore.com/healthplan/Highmark.