Highmark Insurance Denial Appeal Guide

Highmark Appeal Process

As a BCBS affiliate, Highmark follows standard appeal procedures but also has regional variations based on state law.

Common Denial Reasons

• Prior authorization not obtained
• Service not medically necessary per Highmark clinical policies
• Out-of-network provider used
• Benefit limit exceeded
• Experimental/investigational treatment

Appeal Levels

1. First-level internal appeal — submit within 180 days of denial
2. Second-level internal appeal — if available under your plan
3. External review — through your state's external review program
4. State insurance department complaint — PA, DE, WV, or NY department of insurance

Pennsylvania-Specific Tips

• PA Act 68 provides additional consumer protections
• Pennsylvania external review uses CREs (Certified Review Entities)
• PA Department of Insurance: insurance.pa.gov
• PA Health Law Project offers free assistance

Key Documentation

• Always reference Highmark's specific clinical policy that was applied
• Request a copy of the policy from Highmark before writing your appeal
• Highmark uses InterQual criteria for many determinations