Authorization Guidance
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Authorization Guidance

Type a procedure code or name in the search bar to find out if prior authorization is required.

Prior Authorization

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

Obtaining Authorization

Before you submit for prior authorization on Availity, we recommend that you consult Member Eligibility & Benefits. If you don’t have access to Availity, you can review other options below.

Medical Policies

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

MCG Clinical Criteria

Find information on how Highmark incorporates MCG Health evidence-based clinical guidelines into our clinical decision support criteria.

Submission Guidance

Use Availity to submit your prior authorization requests. If you are unable to use Availity, you may also fax prior authorization forms or use EDI 278.

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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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Support

Availity Portal

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

Authorization Workflows

Find answers to questions about authorization workflows, authorization numbers not appearing, members who can't be located, and clinical criteria screens.

Authorization Status

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

Additional Help

Find additional help in the Highmark Provider Manual under chapter 4 the Care and Quality Management section.

Provider Manual – Care and Quality ManagementAuthentication Required

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Clinical Services

Still have questions? Call us: 8:30 a.m. to 7 p.m. Monday through Friday, 8:30 a.m. to 4:30 p.m. Saturday and Sunday.

About Highmark

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Related Sites

®Blue Shield and the Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies.

The following entities serve central and southeastern Pennsylvania and are independent licensees of the Blue Cross Blue Shield Association: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies