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 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.
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 step-by-step reference guides available to assist providers in the authorization process:
We also have resources available for Physical Medicine Management authorizations, which transitioned to Highmark managed in December 2023.
Fax: If you are unable to use the online provider portal, 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 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:
Utilization management of physical medicine services is now managed by Highmark.
To request an authorization for post-acute care services for Medicare Advantage members, you'll need to complete one of the following forms found here.
Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu.
Questions about Availity portal actions.
Questions about authorization workflows.
Registration, user access/ account assistance, portal navigation, error message understanding.
Authorization number not appearing, unable to locate member, questions about clinical criteria screen.
Check status of submitted authorizations.
If you need assistance with an existing account and cannot log in to submit a ticket, or have started the registration process and are experiencing issues, you can call 1-800-AVAILITY (282-4548). For more information about contacting Availity, click HERE.
All Requests: Utilize the Predictal Auth Automation Hub within Highmark's Payer Spaces in Availity.
Inpatient Planned Requests: Call Highmark Clinical Services; Press 2 for authorization requirements/ status.
Last updated on 2/5/2024 4:16:30 PM