Privileging Appeal Process

IMPORTANT NOTE: Effective 12/31/2018, Highmark ended the Radiology Management Program supported by NIA.  NIA will continue to process appeals for prior authorizations issued in 2018, and retro authorizations for service dates in 2018.  For new prior authorizations, and for appeals and retro authorizations for service dates in 2019 and beyond, please see links and guidance under the new Advanced Imaging and Cardiology Services Program.

First Level

Highmark requires that all network providers comply with the terms and conditions of their contracts and meet the applicable requirements for performing imaging services. Highmark has established privileging requirements for providers who bill for imaging services in an outpatient setting.

Highmark provides an appeal process for Highmark Privileging Application denials. The following outlines the procedure for provider appeals of Highmark Privileging Application denials:

1. Written appeals must be requested in writing within 30 days of receiving a denial letter.
   
   
2. Appeals should be submitted on letterhead that indicates the provider name, and includes the billing provider number and tax ID number of the provider/location that has been denied privileges.
   
   
3. Documentation supporting the request for an exception to the Requirements or reason why the decision was incorrect should be included.
   
   
4. Appeals and accompanying documentation should be faxed to 866-552-7589 (This fax number is intended for National Imaging Associates, Inc. (NIA), an affiliate of Magellan Health, Inc., a radiology benefits management firm, application appeals only. Claim denial appeals should not be faxed to this number).
   
   
5. The Highmark Privileging Appeal Hearing Panel will review all submitted documentation and issue a written decision that includes a statement of the basis for the decision, within 60 days of receipt of your appeal.

Second Level

You have the right to appeal a First Level decision to uphold a denial to the Highmark Medical Review Committee. If you choose to appeal the decision to the Medical Review Committee, you must notify Highmark in writing of your desire to appeal no later than 60 days from the date of the First Level Appeal decision letter, at the following address:

Medical Review Committee (MRC) Coordinator
Financial Investigations and Provider Review - 1A L3
Highmark Inc.
PO Box 890089
Camp Hill, PA 17089-0089
(Claim denial appeals should not be sent to this address)

You will be provided with information regarding the appeal process. The appeal will be conducted in accordance with the Guidelines of the Medical Review Committee.

The decision of the Medical Review Committee is final and binding on all parties thereto and not subject to further appeal within Highmark, in a court of competent jurisdiction or otherwise.