Authorization Updates

During the year, Highmark adjusts the List of Procedures and Durable Medical Equipment (DME) Requiring Authorization. For information regarding authorizations required for a member’s specific benefit plan, providers may:

  • Call the number on the back of the member’s card,
  • Check the member’s eligibility and benefits via Availity®
  • Search BlueExchange through the provider’s local provider portal.

These changes are announced in the form of Special Bulletins and other communications posted on Highmark’s Provider Resource Center (PRC). The most recent updates regarding prior authorization are below:

Prior Authorization Changes Occurring on Sept. 30, 2024

Effective Sept. 30, 2024, nearly 100 codes will be added to the prior authorization list, including codes related to the following procedures and/or treatments:

  • Implantable defibrillator
  • Insertion of new or replacement pacemaker; Removal of permanent pacemaker
  • Mastectomy
  • Nasal/sinus endoscopy
  • Rhinoplasty
  • Prostatectomy
  • Revascularization
  • Tonsillectomy and adenoidectomy
  • Transcatheter aortic valve replacement

Codes to be Added to Prior Authorization List

The codes below will not appear on the Prior Authorization list until the effective date of Sept. 30, 2024. To view the codes now, click here.

Electronic Authorization Tool Update: Enhanced Functionality and Important Reminders

Highmark is pleased to announce recent updates to our Electronic Authorization Tool, Predictal, available through Availity Essentials. These updates are designed to improve your experience and streamline the authorization process, and they are available now for you and your staff to start exploring. Key enhancements include:

  • Searchable Provider Dropdown
  • Contact Information Edits
  • "Copy as Performing Provider" Feature

To learn more, click here.

To view the full List of Procedures/DME Requiring Authorization, click REQUIRING AUTHORIZATION in the gray bar near the top of the PRC homepage.

Once redirected to the Procedures/Service Requiring Authorization page, click View the List of Procedures/DME Requiring Authorization under PRIOR AUTHORIZATION CODE LISTS.

Please note that the Highmark member must be eligible on the date of service and the service must be a covered benefit for Highmark to pay the claim.

Availity is the preferred method for:

  • Checking member benefits and eligibility
  • Verifying whether an authorization is needed
  • Obtaining authorization for services


 

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