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Behavioral Health Forms

This page contains Behavioral Health forms for providers to use when communicating with Highmark.

Behavioral Health Fax Number for Authorization Requests: 1-877-650-6112

For precertification or continued stay review requests for Behavioral Health treatment, please submit relevant clinical information via fax to 1-877-650-6112.

Submission of the complete medical record may slow down the process and is not an efficient way to communicate the clinical need for an admission or continued stay review.

Please fax the relevant clinical information to support the treatment request using your own fax format as needed.

For FEP Members Only

Residential Treatment Center (RTC) must be accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance abuse. 

Pre-admission Requirements:

  • Precertification prior to admission
  • A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC), and case manager in the Local Plan where the RTC is located prior to admission.
  • Member must be enrolled and participating in case management through the Local Plan when the care is medically necessary for treatment of a medical, mental health, and/or substance abuse condition.

FEP Nondiscrimination Notice

Last updated on 3/13/2023 4:29:04 PM

 

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Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Highmark Blue Shield serves the 21 counties of central Pennsylvania and also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Blue Cross Blue Shield West Virginia serves the state of West Virginia plus Washington County. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Western and Northeastern New York Inc., serves eight counties in Western New York under the trade name Highmark Blue Cross Blue Shield of Western New York and serves 13 counties in Northeastern New York under the trade name Highmark Blue Shield of Northeastern New York. Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration.