Authorization Guidance

Prior Authorization

Find out how to submit, update, and inquire about authorization requests.

Obtaining Authorization

Before you submit a prior authorization request, we recommend that you check member eligibility & benefits via Availity.

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Medical Policies

We maintain evidence-based coverage guidelines and monitor evolving therapies to ensure appropriate benefit adjudication, patient safety, and optimized treatment.

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Care Management Programs

Highmark offers a wide range of care management programs and policies.

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Clinical Guidance

Find clinical guidance for certain service types from eviCore.

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MCG Clinical Criteria

Highmark incorporates MCG Health evidence-based clinical guidelines into our clinical decision support criteria.

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Inter-Plan Programs

Highmark offers members the ability to access cost-effective health care even when they're outside their plan's service area.

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Member Eligibility & Benefits

Service preapproval is based on the member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits. Eligibility and benefits can be verified by accessing the online provider portal or by calling the number on the back of the member’s identification card.

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EDI 278

Use HIPAA Health Services Review (278) electronic transactions for authorizations.

cpa/ sepa

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neny

READ ABOUT EDI 278 SERVICES

wpa/ nepa

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Support

Availity Portal

Get answers to your questions about Availity portal actions, including registration, user access, account assistance, portal navigation, and error messages.

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Authorization Status

Use the Predictal Auth Automation Hub within Highmark’s Payer Spaces in Availity. For Inpatient Planned Requests, call the appropriate Clinical Services number & press 2 for authorization requirements/status.

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