Highmark requires authorization of certain services, procedures, inpatient level of care for elective/planned surgeries, 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.)
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 online provider portal or by calling the number on the back of the member’s identification card.
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. Please note: If an elective surgery will require an Inpatient Level of Care, prior authorization is required even if the procedure code is not listed on the prior authorization code lists.
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 resources available to assist providers in the authorization process.
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We also have resources available for Physical Medicine Management authorizations, which transitioned to Highmark managed in December 2023.
This link requires authentication. If you are not already logged in you will need to log into Availity and link to this site from there.
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 prior authorization forms can be found using the below link.
This link requires authentication. If you are not already logged in you will need to log into Availity and link to this site from there.
For inquiries that cannot be handled via the online provider portal, call the appropriate number from the PDF below.
Information on Highmark's incorporation of MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support:
Find more information on authorizations in the Highmark Provider Manual - Chapter 5, Care & Quality Management: