Behavioral Health Forms

Last Updated: Friday, December 08, 2023

This page contains Behavioral Health forms for providers to use when communicating with Highmark.

Communication Document for Behavioral Health Specialist To Primary Care Physician

Outpatient Behavioral Health (BH) - ABA Requests: Service Authorization Request - applies to members of FEP and employees of PNC, Albertsons, and Centene

Behavioral Health Fax Number For Authorization Request: 877-650-6112

For precertification or continued stay review requests for Behavioral Health treatment, please submit relevant clinical information via fax to 877-650-6112.

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.

®Blue Shield and the Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies.

The following entities serve central and southeastern Pennsylvania and are independent licensees of the Blue Cross Blue Shield Association: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies