Behavioral Health Forms
Last Updated: Monday, July 01, 2024
This page contains Behavioral Health forms for providers to use when communicating with Highmark.
- wpa/ nepa
- cpa/ sepa
- de
- Discharge Summary Fax Template
- Outpatient Behavioral Health (BH) - ABA Requests: Service Authorization Request - applies to members of FEP and employees of PNC, Albertsons, and Centene
- neny
- wny
- wpa/ nepa
- cpa/ sepa
- wny
- neny
- wpa/ nepa
- cpa/ sepa
- de
- wny
- neny
- wv
Effective July 1, 2024, West Virginia Law (Senate Bill 267) mandates the electronic submission of prior authorization requests. For this reason, Highmark removed West Virginia prior authorization forms from the Provider Resource Center (PRC). All prior authorization requests must now be submitted to Highmark via our provider portal (Availity®).
Use the following template when a member is being discharged:
Behavioral Health Fax Number for Authorization Requests
- wpa/ nepa
- cpa/ sepa
- de
- wv
- 877-650-6112
- wny
- neny
- Inpatient: 833-581-1866
- Outpatient: 833-581-1867
For precertification or continued stay review requests for Behavioral Health treatment, please submit relevant clinical information via fax to the appropriate number above.
Submission of the complete medical record may slow down the process and is not an efficient way to communicate the clinical need for an admission or continued stay review.
Please fax the relevant clinical information to support the treatment request using your own fax format as needed.
