Authorization Requirements

Highmark Blue Shield 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 Blue Shield'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

To check a member's authorization requirements, call the precertification number on the back of their card. Additionally, in-network providers can utilize the online provider portal to check eligibility and benefits for Highmark Blue Shield members; out-of-area providers can check for the member's benefits through BlueExchange via their local portal.

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 Blue Shield will provide written notice when codes are added to the list; deletions are announced via online publication.

View the List of Procedures/DME Requiring Authorization^*

*This is not an all-inclusive list. Benefits can vary; always confirm member coverage.

View the List of FEP Standard and Basic Procedures/DME Requiring Prior Approval
View the List of FEP Blue Focus Procedures/DME Requiring Prior Approval

Obtaining Authorizations 

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 Blue Shield 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.

Videos:

Click the links below to view the videos. If you experience an issue, please refresh your browser. If the issue persists, contact resourcecenter@email.highmark.com.

• Case Management Referral Process (Predictal via Availity)
• Electronic Authorization Submission Process (Predictal via Availity)

Guides:

• Inpatient Authorization Submission (Both Urgent and Non-Urgent)
• Outpatient Authorization Submission

Additional Resource:

• MCG Guidelines Product Acronym List

We also have resources available for Physical Medicine Management authorizations, which are required in our New York markets for members in commercial plans effective May 1, 2024.

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: 833-581-1866
• Gastric Surgery: 833-619-5745
• Durable Medical Equipment/Medical Injectable Drugs/Outpatient Procedures: 833-619-5745
• Inpatient Clinical: 833-581-1868

Telephone: For inquiries that cannot be handled via the online provider portal, call the appropriate Clinical Services number, which can be found here.

For more information on Authorizations, please reference Chapter 5, Unit 2 of the Highmark Provider Manual.