Obtaining Authorizations

You can submit or manage most medical authorization requests quickly and easily via Availity Essentials. It’s your go to tool for managing inpatient and outpatient authorizations — no phone calls, no paperwork. Just a faster, simpler way to verify eligibility, submit authorizations, and manage claims with ease.

Here’s what you can do in the portal:

• Submit new requests for both inpatient and outpatient care.
• Start a retrospective review for services already provided.
• Upload supporting medical documentation right when you submit.
• Withdraw pending requests if they’re no longer needed.

Need access?

• If you haven’t signed up for Availity Essentials yet, now’s a great time to get started. To learn more, go to the Register and Get Started with Availity Essentials webpage.

Pharmacy Authorizations: 

• Submit and track pharmacy authorization requests easily through CoverMyMeds, a secure electronic platform designed to streamline prior authorization processing.  CoverMyMeds is accessible via Highmark's Payer Spaces in Availity.
• You can check the status of your requests online anytime to stay informed and support timely treatment decisions.
• Download required pharmacy prior authorization forms only available when electronic submission is not possible or preferred. 

Fax Submission

Fax forms serve as a backup or alternative method for submitting prior authorizations securely when electronic submission is not possible or preferred.

Download authorization forms for fax submissions:

• Medical Authorization Forms
• Medical Injectable Drug Forms
• Pharmacy Authorization Forms

Submit Using HIPAA 278 Electronic Transactions

• You may be able to submit authorization requests through your clearinghouse or practice management system leveraging Highmark's Electronic Data Interchange (EDI).

Click on the applicable link to access the Highmark EDI Services website directly:

• Pennsylvania: https://edi.highmark.com/edi/index.shtml
• Delaware: https://edi.highmark.com/edi-bcbsde/index.shtml
• West Virginia: https://edi.highmark.com/edi-wv/index.shtml

Note: Highmark's EDI does not currently support HIPAA 278 electronic transactions for New York providers.

Need help navigating the authorization process? We’ve got you covered. 

• Visit Availity for step-by-step workflow guidance and training materials to help you get started.
  • Provider Webinar: Authorization Request and Follow-up for Highmark Providers

Authorization Submission Guides:

Use Availity's Authorizations & Referrals for all initial authorization submissions.

• Availity Inpatient Authorization Submission (Both Urgent and Non-Urgent) 
• Availity Outpatient Authorization Submission 
• Electronic Retrospective Review Request Submission

Use the Predictal Auth Automation Hub to check authorization status, review approval and denial letters, manage discharges and concurrent requests, respond to requests for additional information, and submit extensions.

• Predictal Inpatient Authorization Submission Guide 
• Predictal Outpatient Authorization Submission Guide

•  Submitting an Extension Request

• Behavioral Health Tip Sheet for Submitting Authorization Requests
• Guide to Out-of-Network Gap Exception Requests

The "Learn How to Submit and Authorization" resource was temporarily removed in September 2025 as Highmark transitions to Availity’s Authorizations & Referrals workflow for initial medical authorization requests. This resource will be reinstated at a future date.

For services managed by eviCore, visit the eviCore Highmark Provider Resources page for guidelines and support. 

MCG Guidelines:

• Highmark uses MCG’s evidence-based guidelines to streamline the authorization process and support clinical decision-making.

Check Service Coverage: 

• Confirm your service or request is covered under Highmark’s use of MCG (note: some delegated services may not apply).  Refer to the instructions on how to access the MCG guidelines.

Need Help?

• For questions or assistance, contact mcgquestions@highmarkhealth.org.