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Authorization Management

Last Updated: Tuesday, July 21, 2026

The preferred — and fastest — method to submit authorization requests and receive approvals is via Highmark’s provider portal, Availity Essentials.

For additional information and resources on submitting authorizations, go to the following page:

Obtaining AuthorizationsAuthentication Required

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Highmark partners with vendors for the management of prior authorization for certain services.

Laboratory Management

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The Laboratory Management Program is not applicable to New York.

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Highmark has partnered with eviCore to manage molecular/genomic, and non-molecular testing within the Laboratory Management Program. The Laboratory Management Program utilizes evidence-based policies, developed with trained experts, to ensure that the lab services provided to Highmark's members support clinically appropriate care and are medically necessary, in accordance with their benefit policy.

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

These tests include:

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

Highmark requires claims review for several non-molecular tests when performed in an outpatient setting for fully insured Commercial, Affordable Care Act (ACA), and Medicare Advantage members. A prior authorization is not required for these tests.

These tests include:

Cardiovascular Disease Risk Panels
Allergy Testing
Drug Testing
Celiac Disease
Vitamin D Testing
Thyroid Testing

Highmark has adopted eviCore’s molecular/genomic, and non-molecular testing policies. Policies and a complete list of impacted procedure codes are available here.

Learn More About the Laboratory Management Program

eviCore has a dedicated webpage for Highmark providers to conveniently access evidence-based clinical guidelines, the current CPT code list, important resources, and recent announcements. We encourage you to visit their site to ensure that you have the most current information:

eviCore Highmark Provider Resources

Reference Materials

Laboratory Management Program Administrative Guide
- This guide includes a summary of all components of the Laboratory Management Program.
eviCore Prior Auth Quick Reference Guide

Musculoskeletal Surgery and Interventional Pain Management Services

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

Oncology

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.

Radiation Therapy

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The Radiation Therapy Authorization Program is not applicable to New York.

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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.

Resource

Radiation Therapy Clinical Guidelines