Effective May 1, 2024, Highmark Blue Shield providers will need to request prior authorization for outpatient physical therapy (PT), occupational therapy (OT), and home health services.

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PT and OT – Commercial Plans

For Highmark Blue Shield members in Commercial plans, outpatient physical therapy and occupational therapy will require prior authorization starting May 1, 2024; however, authorization is not required for the initial evaluation.

*Administrative Services Only (ASO), Federal Employee Program (FEP), and Medicare Advantage are excluded from the prior authorization requirement.

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Home Health – Commercial Plans and ASO Groups

For Highmark Blue Shield members in Commercial plans and ASO groups, providers will need to request authorization for home health services, now starting May 1, 2024.

Note: Medicare Advantage is excluded from the prior authorization requirement; FEP prior authorization not required for initial visits, per the plan limit. If a member needs additional visits (beyond the plan limit), then prior authorization is required.

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Prior Authorization Requests

Providers will be able to submit electronic prior authorization requests beginning April 26, 2024, for services occurring on or after May 1, 2024.

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Training

Training videos are available on the Provider Resource Center (PRC) by clicking here. The recordings are listed under Instructional Videos.

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Chiropractic CPT Codes Will Not Require Prior Authorization

Highmark has made the decision not to add chiropractic CPT codes to New York’s prior authorization list; the following codes will not require prior authorization: 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, and 98943. View the latest prior authorization list here.

Providers are encouraged to always check a member’s eligibility and benefits in Availity Essentials to ensure you are aware of their coverage and benefit limits.

If chiropractors are performing and billing for non-chiropractic CPT codes, they should check the prior authorization list to see if those codes require prior authorization.

Practitioners who perform and bill with non-chiropractic CPT codes are encouraged to view the training videos on the PRC.