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Prior Authorization Code Lookup
Now you can search CPT codes from anywhere on the Highmark Health Options Provider Resource Center. Simply enter the code in the main site search bar above to determine whether prior authorization is required.
Disclaimers:
This prior authorization list provides general guidance and is not exhaustive. Prior authorization is for medical necessity only and does not guarantee payment. Final determinations are dependent upon individual member benefits, medical necessity, and clinical guidelines at the time of service. Medications necessary for procedures may require prior authorization separate from or in addition to authorization requirement(s) for procedure(s).
Additional prepay/post service edits may apply. Refer to the WV Department of Human Services Bureau for Medical Services website for BMS-required J3490 Code and Drug Code List edits.
With or without a result above, for WV Medicaid, WVCHIP, and Medicare D-SNP (HMO SNP), prior authorizations are required for:
- All inpatient admissions, including organ transplants.
- Elective inpatient surgeries. (Elective outpatient surgeries NOT on the prior authorization list do NOT require an auth unless the provider is non-PAR.)
- Any service that requires an authorization from a primary payer, except nonexhausted Original Medicare Services.
- Any exhausted or noncovered Original Medicare service.
- All non-par provider services or out-of-state provider services.
- Covered services with no fee attached. Unlisted or unspecified procedure codes.
In addition, for Medicaid, the following items also always require prior authorization:
- Home Health Care
- Hospice Services
- Musculoskeletal surgery procedures
- Potentially experimental, investigational, or cosmetic services
Reminder: Third-party prior authorizations for Highmark Health Options include VSP Vision Care, HealthHelp, and United Concordia Dental.
Have questions?
We can help. Review the Prior Authorizations section of the current Provider Manual or call Provider Services at 1-833-957-0020, Monday–Friday, 8 a.m.–5 p.m. Or contact your Provider Account Liaison.
Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)
To comply with the CMS Interoperability and Prior Authorization final rule, Highmark Health Options is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year.
You can find additional information, here.
