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.)

MCG Clinical Criteria - Information on Highmark's incorporation of MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support.

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 NaviNet^® 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

Examples of services that may require authorization include the following. 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)
• Speech Therapy services, including those provided to Medicare Advantage members
• Home Health 
• Potentially experimental, investigational, or cosmetic services
• Select DME
• Select injectable drugs covered under the member's medical plan
• Oxygen
• Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
• Certain outpatient procedures, services, supplies. 

Obtaining Authorizations 

Portal: The preferred - and fastest - method to submit preauthorization requests and receive approvals is NaviNet^®. The online portal is designed to facilitate the processing of authorization requests in a timely, efficient manner. Providers who do not have NaviNet, can use the HIPAA Health Services Review (278) electronic transactions for some types of authorizations.

If you are a Highmark network provider and have not signed up for NaviNet, learn how to do so here.

Highmark recently launched the Auth Automation Hub utilization management tool that allows offices to submit, update, and inquire on authorization requests.

• Inpatient Authorization Guides:
  • Non-Urgent Inpatient Authorization Submission: Step-by-step non-urgent inpatient authorizations reference guide.
  • Urgent Inpatient Authorization Submission: Step-by-step urgent inpatient authorizations reference guide.
• Outpatient Authorization Guide: Step-by-step outpatient authorizations reference guide.
  
  • MCG Guidelines Product Acronym List
• Helion Arc Authorization Guide: Step-by-step Helion Arc authorizations reference guide.
• Auth Automation Hub Frequently Asked Questions

For additional resources on the Helion Arc authorization process, including instructional videos, CLICK HERE.

Fax: If you are unable to use NaviNet, you may also fax your authorization requests to one of the following departments. The associated preauthorization forms can be found here.

• Behavioral Health: 877-650-6112
• Gastric Surgery/Therapy/Durable Medical Equipment/Outpatient Procedures: 888-236-6321
• Home Health/Home Infusion Therapy/Hospice: 888-567-5703
• Inpatient Clinical: 800-416-9195
• Medical Injectable Drugs: 833-581-1861
• Musculoskeletal (eviCore): 800-540-2406

Telephone: For inquiries that cannot be handled via NaviNet, 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

Highmark contracts with WholeHealth Living, a Tivity Health company, for physical medicine services - and naviHealth for Post-Acute Care for Medicare Advantage members.

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

Support