Obtaining Authorizations

Highmark requires authorization of certain services, procedures, inpatient level of care for elective/planned surgeries, 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 information 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.)

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.

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.

• View the List of Procedures/DME Requiring Authorization
• 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

The preferred – and fastest – method to submit preauthorization requests and receive approvals is the online provider portal. 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.

Highmark launched the Predictal Auth Automation Hub utilization management tool that allows offices to submit, update, and inquire on authorization requests. We have a number of step-by-step reference guides available to assist providers in the authorization process.

Videos

Click the links below to view the videos.* If you experience an issue, please refresh your browser. If the issue persists, contact resourcecenter@email.highmark.com.

• Case Management Referral Process (Predictal via Availity)
  
• Electronic Authorization Submission Process (Predictal via Availity)

Video Disclaimer

*By accessing the videos above, I understand that I am leaving the Highmark PRC website and will be redirected to an external website operated by a third-party platform provider. Any use of the third-party platform provider’s website and any information you provide will be subject to and governed by the terms of the third party, including those relating to confidentiality, data privacy, and security.

Guides

• Inpatient Authorization Submission (Both Urgent and Non-Urgent)
• Outpatient Authorization Submission

Physical Medicine Management Authorizations

We also have resources available for Physical Medicine Management authorizations, which transitioned to Highmark managed in December 2023.

Additional Resource

MCG Guidelines

• MCG Guidelines Product Acronym List
  

If you are unable to use the online provider portal, you may also fax your authorization requests to one of the following departments. The associated prior authorization forms can be found using the below link.

• Behavioral Health: 877-650-6112
• Gastric Surgery/Therapy/Durable Medical Equipment/Outpatient Procedures: 888-236-6321
• Home Health/Home Infusion Therapy/Hospice: 888-567-5703
• Inpatient Clinical: 800-416-9195
• Medical Injectable Drugs: 833-581-1861
• Musculoskeletal (eviCore): 800-540-2406

For inquiries that cannot be handled via the online provider portal, call the appropriate number from the PDF below.

Clinical Services number