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Utilization Management: Coverage and Denial Processes

Date:
September 22, 2022

Coverage Decisions Based on Appropriateness of Care

Medical necessity decisions are made on the appropriateness of care and services. Coverage decisions are based on the benefits and provisions contained in patients’ contracts. We do not reward or offer incentives to practitioners, providers, or staff members for issuing denials or for encouraging inappropriate under-utilization of care.

Discussing an Adverse Determination

Legacy System Patients

If you would like to discuss a denial decision based on medical necessity with our physician reviewers for a Highmark Blue Cross Blue Shield of Western New York legacy system patient, please call 1-800-677-3086.

You can also discuss adverse determinations with our physician reviewers when you are notified of our determination. Criteria used by Utilization Management to render our decisions can be found here.

 You may also request the criteria by calling the number above or by sending a written request to:

Highmark Blue Cross Blue Shield of Western New York
Attn: Utilization Management
PO Box 80
Buffalo, NY 14240

Highmark System Patients

If you would like to discuss a denial decision based on medical necessity for your Highmark system patients, please call 1-844-946-6263.

You can also discuss adverse determinations with our physician reviewers when you are notified of our determination. Criteria used by Utilization Management to render our decisions can be found here. You may also request the criteria  by calling the number above or by sending a written request to:

Highmark Blue Cross Blue Shield of Western New York
Attn: Utilization Management
PO Box 4208
Buffalo, NY 14240

For both your legacy and Highmark system patients, you may also obtain criteria in person at:

Highmark Blue Cross Blue Shield of Western New York
257 West Genesee Street
Buffalo, NY 14202

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