Highmark Blue Cross Blue Shield of Western New York (Highmark BCBSWNY) 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 BCBSWNY'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 NaviNet® to check eligibility and benefits for Highmark BCBSWNY 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 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
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 is rolling out the Auth Automation Hub utilization management tool that allows offices to submit, update, and inquire on authorization requests. We have a number of step-by-step reference guides available to assist providers in the authorization process:
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: 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 NaviNet, call the appropriate Clinical Services number, which can be found here.
Care Management Programs
Highmark Blue Cross Blue Shield of Western New York has partnered with eviCore healthcare (eviCore) for the Advanced Imaging and Cardiology Services Program. Effective date TBD, eviCore will also manage prior authorizations for molecular/genomic and non-molecular testing, musculoskeletal (MSK) surgery and interventional pain management (IPM) services, and radiation oncology therapy services. (Subject to New York State Department of Health approval.)
Additional information about the programs and links to prior authorization codes are available under Care Management Programs in the left website menu.
For more information on Authorizations, please reference Chapter 5, Unit 2 of the Highmark Provider Manual.
Last updated on 5/19/2023 9:44:17 AM