Prior Authorization Code Lookup

Now you can search CPT codes from anywhere on the Highmark Wholecare Provider Resource Center. Simply enter the code in the main site search bar above to determine whether prior authorization is required.

Disclaimers:

The 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).

With or without a result using the main site search bar, for PA Medicare and Medicaid, prior authorizations are required for:

All inpatient admissions, including organ transplants.
Elective surgeries.
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
Muskuloskeletal surgery procedures
Potentially experimental, investigational, or cosmetic services

Prior Authorization Code Lists

Effective June 1, 2026: Prior Authorization Updates

Effective May 1, 2026: Prior Authorization Updates

Effective April 1, 2026: Prior Authorization Updates

Effective Feb. 1, 2026: Prior Authorization Updates

Effective Dec. 1, 2025: Prior Authorization Updates

Post-Acute Care Authorization Submissions

Effective March 1, 2026, post-acute care authorization for Wholecare D-SNP members will be moving to the GuidingCare platform, which is accessible via NaviNet. Training materials related to post-acute care authorizations can be accessed here.

Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)

To comply with the CMS Interoperability and Prior Authorization final rule, Highmark Wholecare 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.