Highmark West Virginia requires authorization of certain services, procedures, and/or 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 site is intended to serve as a reference summary that outlines where information about Highmark West Virginia'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.)
Episodes of Care may be available for some services for Commercial Fully Insured, ACA, ASO Opt-In, Medigap and Medifil members.
The following circumstances require an authorization. Member Benefits can vary; always confirm member coverage.
The ordering provider is typically responsible for obtaining authorizations for the procedures, services, drugs, devices, treatment and durable medical equipment that require prior authorization. The procedure codes contained on these lists requiring authorization and related effective dates are subject to change. Highmark West Virginia will provide written notice when codes are added to the list; deletions are announced via online publication.
NOTE: DO NOT BOOKMARK THESE LISTS AS THEY ARE SUBJECT TO CHANGE; BOOKMARK INSTEAD THE URL FOR THIS PAGE/SITE.
The services on these lists require authorization. Please be sure to verify the member’s coverage before providing services.
To SEARCH for a specific procedure code on these lists, press Control key + F key, enter the procedure code and press Enter.
The lists includes services and procedures such as:
- Potentially experimental, investigational, or cosmetic services
- Select DME
- Select injectable drugs covered under the member's Medical plan (See additional information below.)
- Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
- Certain outpatient procedures, services, supplies.
Member Benefits can vary; always confirm member coverage.
Last updated on 7/28/2021