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. 

Disclaimers

This prior authorization list provides general guidance and is not exhaustive. Prior authorization is for medical necessity only and does not guarantee payment. Final determinations are dependent upon individual member benefits, medical necessity, and clinical guidelines at the time of service. Medications necessary for procedures may require prior authorization separate from or in addition to authorization requirement(s) for procedure(s).

With or without a result above, for DE Medicaid, Medicare, and D-SNP, 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

Reminder: third-party prior authorizations for Highmark Health Options include VSP Vision Care, 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.