Authorization Requirements

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.) 

The following circumstances are representative of those that require an authorization. This is not an all inclusive list. Benefits can vary; always confirm member coverage.

  • Inpatient admissions (e.g., acute inpatient, skilled nursing facility, rehabilitation hospital, behavioral health facility, long-term acute care facility)
  • Procedures/services on Highmark's List of Procedures/DME Requiring Authorization (see below)
  • Home Health 

The ordering provider is typically responsible for obtaining authorizations for the procedures/services included on the List of Procedures/DME Requiring Authorization. The procedure codes contained on the list 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. 

VIEW the List of Procedures/DME Requiring Authorization

NOTE: DO NOT BOOKMARK THE LIST AS IT IS SUBJECT TO CHANGE; BOOKMARK INSTEAD THE URL FOR THIS PAGE/SITE.
The services on the List require authorization. Please be sure to verify the member’s coverage before providing services. 


To SEARCH for a specific procedure code on the List of Procedures/DME Requiring Authorization, press Control key + F key, enter the procedure code and press Enter.

The List includes services such as:

  • Potentially experimental, investigational, or cosmetic services
    Select DME
  • Select injectable drugs covered under the member's Medical plan (See additional information below.)
    Oxygen
  • Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
  • Certain outpatient procedures, services, supplies. Benefits can vary; always confirm member coverage.
Last updated on 10/11/2018

 

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