Authorization Requirements

Highmark requires authorization of certain services, procedures, 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.)

For Members

Some types of health care services and supplies require prior authorization from Highmark before you can receive them. This means your provider needs our approval before they can provide these services to ensure that:

• Your benefit plan covers the service. Service preapproval is based on the member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits.
• You receive the most appropriate care: We review your provider's request to make sure the service is medically necessary and aligns with your health needs.
• Your care is cost-effective: We work to ensure that the services you receive are both effective and affordable.

What You Need to Do:

• Talk to your provider: Your provider is responsible for checking if a service requires prior authorization. They have access to Highmark’s prior authorization list on the Provider Resource Center, and the ability to check your benefits via Availity, our provider portal.
• Be prepared: If your provider determines that a service requires prior authorization, they will initiate the process.

If you have any questions or need assistance, please call Member Services using the number on the back of your Member ID card.

For Providers 

Member Eligibility and Benefits

Service preapproval is based on the member’s benefit plan/eligibility at the time the service is reviewed/approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits.

Eligibility and benefits can be verified by accessing the provider portal or by calling the number on the back of the member’s identification card.

Prior Authorization Code Lists

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.

• 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

Obtaining Authorizations 

Portal: 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 resources 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)

Guides:

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

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

Additional Resources:

• Behavioral Health Tip Sheet for Submitting Authorization Requests
• MCG Clinical Criteria - Information on Highmark's incorporation of MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support.
  • MCG Guidelines Product Acronym List

Telephone: For inquiries that cannot be handled via the online provider portal, call the appropriate Clinical Services number, which can be found here.

Additional information on authorizations can be found in Chapter 5 (Care & Quality Management) of the Highmark Provider Manual.

Care Management Programs

Highmark has partnered with eviCore healthcare (eviCore) for the following programs:

• Advanced Imaging and Cardiology Services Program
• Laboratory Management Program
• Musculoskeletal Surgery and Interventional Pain Management Services Prior Authorization Program
• Radiation Therapy Authorization Program

Utilization management of physical medicine services is now managed by Highmark. For Post-Acute Care for Medicare Advantage members, Highmark contracts with Home & Community Care Transitions.

Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu.

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