Provider Manual and Resources

Resources

Find Out If a Service Requires Prior Authorization

Use the online Prior Authorization Code Lookup for Medicaid or Medicare D-SNP and search by codes. Updated regularly, this document lists codes and prior authorization requirements for medical procedures and services. The contents of this list are subject to change in accordance with plan policies and procedures and the Provider Manual.

Pharmacy Prior Authorization with CoverMyMeds

CoverMyMeds helps patients get the medication they need to live healthy lives by streamlining the prior authorization (PA) process for providers and pharmacists. Start today by creating a free account, or logging in to your existing account at CoverMyMeds.com.

Prior Authorization with HealthHelp

Highmark Health Options and Highmark Health Options Duals requires prior authorization from HealthHelp for the following services: 

  • Musculoskeletal: Spine, knee, hip surgeries
  • Pain Management
  • Advanced Imaging: CT scans, PET scans, MRIs, etc.
  • Cardiology
  • Sleep Studies
  • Radiation Oncology

To help streamline how you manage these requests for your Highmark Health Options Duals (HMO-SNP) and Highmark Health Options* patients, HealthHelp is implementing Single Sign-On (SSO) capability within NaviNet on January 1.

If you are an existing NaviNet user, you will need to:

  1. Log in to NaviNet with your credentials.   
  2. Under the drop-down menu for Health Plans, select Highmark Health Options – Delaware D-SNP OR Highmark Health Options Delaware – Medicaid (starting March 2025).
  3. From there, select HealthHelp from Workflows for this Plan on the left-side menu.
  4. If you’re a first time SSO user, you will need to register with an email and password.
  5. Click register and you will be immediately connected to HealthHelp to enter your authorization request**

 

*SSO for HealthHelp through NaviNet will be available for Highmark Health Options in March 2025. Prior Authorization requests for HHO patients should be sent to HealthHelp via fax at 877-637-6934 or by phone at 877-761-1444.

If you are contracted with both HHO Duals and HHO, you will have access to SSO through NaviNet. Authorization requests for HHO (Medicaid) patients can be put through by selecting Highmark Health Options – Delaware D-SNP.

** Note: If you already have an email on file, you will need to click “link account”.

Registering for NaviNet

If you do not already have a NaviNet account for other health plans, you will need to register to access HealthHelp SSO for prior authorization requests.

Get started with NaviNet today. 

Highmark Health Options Community Support

Find help for your patients based on unique needs and location. The free, anonymous search feature can help you and your patients find care, education, food, housing, legal, money, work, and more. Start searching for resources by visiting Community Support and entering a ZIP code. Find help today.

FDA MedWatch Voluntary Safety Reporting

Health professionals, patients, and consumers can voluntarily report adverse events of human medical products. Adverse events may be suspected or observed, and they include problems or use/medication errors. Voluntary reporting helps bring to attention to unknown risks for FDA-approved medical products. Reporting can be done by phone, by fax, through the FDA MedWatch online reporting portal, or by downloading, completing, and submitting the FDA Form 3500 (Voluntary Reporting).

Provider Contracts

Fee Schedule and Procedure Codes

Standard Rates for medical specialty drugs and injections are reimbursed at the Average Sale Price (“ASP”) minus 6%. For more information, call Provider Services at 1-844-325-6251, Monday–Friday, 8 a.m.–5 p.m.