Obtaining Authorizations
Last Updated: Tuesday, December 03, 2024
Highmark requires authorization of certain services, procedures, and/or Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) prior to performing the procedure or service. The authorization is typically obtained by the ordering provider. Some authorization requirements vary by member contract.
This site is intended to serve as a reference summary that outlines where information about Highmark's authorization requirements can be found. This information should not be relied on as authorization for health care services and is not a guarantee of payment.
- wv
For Members
Some types of health care services and supplies require prior authorization from Highmark before you can receive them. This means your provider needs our approval before they can provide these services to ensure that:
- Your benefit plan covers the service: 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.
- You receive the most appropriate care: We review your provider's request to make sure the service is medically necessary and aligns with your health needs.
- Your care is cost-effective: We work to ensure that the services you receive are both effective and affordable.
What You Need to Do:
- Talk to your provider: Your provider is responsible for checking if a service requires prior authorization. They have access to Highmark’s prior authorization list on the Provider Resource Center, and the ability to check your benefits via Availity, our provider portal.
- Be prepared: If your provider determines that a service requires prior authorization, they will initiate the process.
If you have any questions or need assistance, please call Member Services using the number on the back of your Member ID card.
For Providers
Member Eligibility and 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 Availity, Highmark’s provider portal, or by calling the number on the back of the member’s identification card. Out-of-area providers can check for the member's benefits through BlueExchange in their local portal.
Prior Authorization Code Lists
The procedure codes contained in the lists below usually require authorization (based on the member’s benefit plan/eligibility). Effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication.
- wpa/ nepa
- cpa/ sepa
- de
- wv
- View the List of Procedures/DME Requiring Authorization
- This is not an all-inclusive list. Benefits can vary; always confirm member coverage.
- View the List of FEP Standard and Basic Procedures/DME Requiring Prior Approval
- View the List of FEP Blue Focus Procedures/DME Requiring Prior Approval
Please note: If an elective surgery will require an Inpatient Level of Care, prior authorization is required even if the procedure code is not listed on the prior authorization code lists.
- wny
- neny
- View the List of Procedures/DME Requiring Authorization
- This is not an all-inclusive list. Benefits can vary; always confirm member coverage.
- View the List of FEP Standard and Basic Procedures/DME Requiring Prior Approval
- View the List of FEP Blue Focus Procedures/DME Requiring Prior Approval
Please note: If an elective surgery will require an Inpatient Level of Care, prior authorization is required even if the procedure code is not listed on the prior authorization code lists.
Provider Portal
Effective Oct. 1, 2024, all medical prior authorization requests must be submitted through the Availity provider portal. Pharmacy requests should continue to be submitted via CoverMyMeds.
The online provider portal (Availity) is designed to facilitate the processing of authorization requests in a timely, efficient manner. Providers who do not have Availity can use the HIPAA Health Services Review (278) electronic transactions for some types of authorizations.
- wv
*West Virginia providers must submit via the portal as of July 1, 2024, per WV code 33-24-7s.
Resources
We have a number of resources available to assist providers with the change and the electronic authorization process for these outpatient services.
We also have information available regarding our Physical Medicine Management program(s).
Telephone
For inquiries that cannot be handled via the online provider portal, call the appropriate number from the PDF below.
- wny
- neny
If the authorization request is for a patient who is under 21 years old and considered medically fragile, please call our Clinical Services number.
Support
|
Availity Portal |
Authorization Workflows |
Authorization Status |
|---|---|---|
|
Questions about Availity portal actions. |
Questions about authorization workflows. |
|
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Registration, user access/ account assistance, portal navigation, error message understanding. |
Authorization number not appearing, unable to locate member, questions about clinical criteria screen. |
Check status of submitted authorizations. |
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If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 1-800-AVAILITY (282-4548). For more information about contacting Availity, click HERE. |
For questions about authorization, call Provider Service. |
All Requests: Utilize the Predictal Auth Automation Hub within Highmark's Payer Spaces in Availity. Inpatient Planned Requests: Call Highmark Clinical Services; Press 2 for authorization requirements/ status |
- wpa/ nepa
- cpa/ sepa
- de
- wv
Care Management Programs
Highmark has partnered with eviCore healthcare (eviCore) for the following programs:
- Advanced Imaging and Cardiology Services Program
- Laboratory Management Program
- Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program
- Radiation Therapy Authorization Program
Information on these and other programs can be found under Policies & Programs and then Care Management.
Related Links
Find comprehensive medical policy guidelines for all of Highmark’s medical-surgical products, including managed care.
Information on Highmark's incorporation of MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support:
The Highmark Provider Manual has a section on authorizations in Chapter 5, Care & Quality Management:
