Authorization Updates

During the year, Highmark adjusts the List of Procedures and Durable Medical Equipment (DME) Requiring Authorization. For information regarding authorizations required for a member’s specific benefit plan, providers may:

  • Call the number on the back of the member’s card,
  • Check the member’s eligibility and benefits via Availity®, or
  • Search BlueExchange through the provider’s local provider portal.

These changes are announced in the form of Special Bulletins and other communications posted on Highmark’s Provider Resource Center (PRC). The most recent updates regarding prior authorization are below:

New West Virginia Law Mandating Electronic Authorization Requests

State Senate Bill 267 — which will go in effect July 1, 2024 — requires that all prior authorization requests be submitted electronically. If your office or organization isn’t currently using Availity to submit authorization requests, now’s the time to get started. July 1 will be here sooner than you think. For more information, see the article in November Provider News by clicking here.

CoverMyMeds Auth Requests: Always Include BIN, PCN, and RXGroup Information

To view the full List of Procedures/DME Requiring Authorization, click REQUIRING AUTHORIZATION in the gray bar near the top of the PRC homepage.

Once redirected to the Procedures/Service Requiring Authorization page, click View the List of Procedures/DME Requiring Authorization under PRIOR AUTHORIZATION CODE LISTS.

Please note that the Highmark member must be eligible on the date of service and the service must be a covered benefit for Highmark to pay the claim.

Availity® is the preferred method for:

  • Checking member benefits and eligibility
  • Verifying whether an authorization is needed
  • Obtaining authorization for services


 

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