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.)
ATTENTION: Temporary authorization procedure for authorizations submitted between August 22–October 3, 2002.
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.
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
- Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
- Certain outpatient procedures, services, supplies.
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 a utilization management tool, Predictal, that allows offices to submit, update, and inquire on medical inpatient authorization requests.
- Inpatient Authorization Guide: Click here for the Predictal step-by-step inpatient authorizations reference guide.
- Outpatient Authorization Guide: Click here for the Predictal step-by-step outpatient authorizations reference guide.
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:
Highmark contracts with WholeHealth Networks, Inc. (WHN), a subsidiary of Tivity Health Support, LLC., for physical medicine services.
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 NaviNet 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.
Mon.-Fri., 8am - 11pm ET
Sat., 8am - 3pm ET
All Requests: Utilize “Authorization Inquiry” function in NaviNet.
Inpatient Planned Requests: Call Highmark Clinical Services; Press 2 for authorization requirements/ status.
Last updated on 11/23/2022 11:19:17 AM