Medicaid Prior Authorization Code Lookup

Find out if prior authorization from Highmark Health Options is required for medical procedures and services. Enter a Current Procedural Terminology (CPT) code in the space below to get started. 

With or without a result above, for DE Medicare and Medicaid, prior authorizations are required for:

• All inpatient admissions, including organ transplants.
• Elective inpatient surgeries. (Elective outpatient surgeries NOT on the prior authorization list do NOT require an auth unless the provider is non-PAR.)
• Any service that requires an authorization from a primary payer, except nonexhausted Original Medicare Services.
• Any exhausted or noncovered Original Medicare service.
• All non-par provider services or out-of-state provider services.
• Covered services with no fee attached.
• Unlisted or unspecified procedure codes.

In addition, for Medicaid, the following items also always require prior authorization:

• Home Health Care
• Hospice Services
• Musculoskeletal surgery procedures
• Potentially experimental, investigational, or cosmetic services
• Power Wheelchairs and wheelchair replacement parts or accessories
• Prosthetics

The contents of this list are subject to change in accordance with plan policies and procedures and the Provider Manual. Providers should consult applicable medical policies for information regarding covered benefits. Recommendations contained in InterQual guidelines are not a guarantee of coverage.

As a reminder, third-party prior authorizations for Highmark Health Options include VSP Vision, HealthHelp, and United Concordia Dental.

Have questions?

We can help. Review the Prior Authorizations section of the Provider Manual. Call Provider Services at 1-844-325-6251, Monday–Friday, 8 a.m.–5 p.m. Or contact your Provider Account Liaison.