Highmark requires authorization of certain services, procedures, and/or 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 site 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.)
Obtaining Authorizations Providers who have the Highmark NaviNet® system should use NaviNet to obtain authorizations for Highmark members. Providers who do not have NaviNet can use the HIPAA Health Services Review (278) electronic transactions for some types of authorizations. (If you are not NaviNet enabled, please contact your Provider Relations representative to learn about the benefits of conducting business electronically with Highmark.) If you must submit a telephonic request, call the appropriate phone number below to reach Medical Management & Policy:
Western Region: 1-800-547-3627
Central, Eastern and Northeastern Regions: 1-866-731-8080
For Medicare Advantage Members, call:
FreedomBlue PPO: 1-866-588-6967
Medicare Advantage HMO: 1-866-517-8585
The following circumstances are representative of those that require an authorization. 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)
- Procedures/services on Highmark's List of Procedures/DME Requiring Authorization (see below)
- Speech Therapy services, including those provided to Medicare Advantage members
- Home Health
The ordering provider is typically responsible for obtaining authorizations for the procedures/services included on the List of Procedures/DME Requiring Authorization. The procedure codes contained on the list requiring authorization and related effective dates are subject to change. Highmark will provide written notice when codes are added to the list; deletions are announced via online publication.
The services on the List require authorization. Please be sure to verify the member’s coverage before providing services.
To SEARCH for a specific procedure code on the List of Procedures/DME Requiring Authorization, press Control key + F key, enter the procedure code and press Enter.
The List includes services such as:
- Potentially experimental, investigational, or cosmetic services
- Select DME
- Select injectable drugs covered under the member's Medical plan (See additional information below.)
- Select Not Otherwise Classified (NOC) procedure codes, i.e., unlisted, miscellaneous, Not Otherwise Specified (NOS)
- Certain outpatient procedures, services, supplies. Benefits can vary; always confirm member coverage.
Last updated on 4/1/2022 9:21:55 AM