Authorization Management Vendors

Laboratory/Genetic Testing Utilization Management Program

Highmark is engaging HealthHelp, a specialty benefit management company, to assist Highmark in applying evidence-based medical criteria and expert peer consultation to ensure appropriate utilization of molecular lab services. 

Highmark requires prior authorization for molecular/genomic tests when performed in an outpatient setting for fully insured Commercial, Affordable Care Act (ACA), CHIP, and Medicare Advantage members.

These tests include:

• Cardiovascular
• Disease and Thrombosis Risk Variant Testing
• Carrier
• Screening Tests
• Hereditary
• Cancer Screening
• Hereditary
• Cardiac Disorders
• Intellectual
• Disability/Developmental Disorders
• Mitochondrial
• Disease Testing
• Neurologic
• Disorders
• Pharmacogenomic
• Testing
• Tumor
• Marker/Molecular Profiling

Learn More about the Laboratory/Genetic Testing UM Program

HealthHelp has a dedicated webpage for Highmark providers that includes evidence-based clinical guidelines, the current CPT code list, important resources, and recent announcements.

Highmark requires prior authorization for inpatient and outpatient musculoskeletal (MSK) and interventional pain management (IPM) procedures. New and continuing authorization requirements for inpatient and outpatient MSK and IPM services are managed directly by Highmark as of May 1, 2026.

These requirements apply to Highmark members enrolled in our fully insured Commercial, Medicare Advantage, and Affordable Care Act (ACA) plans, as well as members of select self-insured (Administrative Services Only) groups.

MSK procedures that require authorization include the following:

• Large joint surgeries
• Spine surgeries

Highmark has partnered with Evolent to manage medical and radiation oncology authorization requests for certain members as part of our oncology value-based care strategy. This collaboration aims to enhance clinical outcomes and streamline the authorization process.

Note: This information is for reference only and does not guarantee authorization or payment.

Evolent's clinical pathways do not replace third-party pathway tools. Practices may continue using established pathways in parallel with submitting oncology authorization requests.

Highmark members* included in Evolent’s authorization reviews are:

• Commercial fully insured; Affordable Care Act (ACA); and Medicare Advantage members in Delaware, Pennsylvania, and West Virginia
• Medicare Advantage members in New York
• Pennsylvania Child Health Insurance Program (CHIP) members

*Radiation Oncology Authorization requests for Highmark Administrative Services Only (ASO) members will also continue to be requested through Availity but remain under eviCore review.

Requesting Authorization

Initial oncology authorization requests should be submitted through Availity.

Note: For Evolent-managed requests that go to review, providers must upload supporting clinical documentation directly to the Evolent CarePro portal.

If you have questions about Evolent programs, email providertraining@evolent.com.