How to verify authorization

Providers must verify member-specific authorization requirements before submitting any prior authorization (PA) or utilization management (UM) request. Check the phone number on the back of the member’s ID card, confirm eligibility and benefits via Availity, or search BlueExchange® through the provider portal to determine whether PA is required for the member’s plan.

• How to verify authorization: call the number on the back of the member's card; check Availity eligibility/benefits; search BlueExchange through local provider portal.

Prior authorization / utilization management routing

Prior authorization and UM routing are code- and diagnosis-dependent. Many procedures and drugs in the code lists are designated either Highmark Management Services, Highmark Advanced Imaging, Highmark Specialty/Site-of-Care, or Evolent (Evolent Oncology UM Program). Submit the exact CPT/HCPCS/J-/Q-code and the member’s diagnosis on the request so the service is routed to the correct manager.

• Many listed procedures are designated as Highmark Management Services, Highmark Advanced Imaging, Highmark Specialty (including Site of Care), or Evolent Oncology — use the code-to-program mapping when requesting UM review.
• Procedure code and diagnosis routing: include the CPT/HCPCS/J-/Q-code and indicate whether the diagnosis is cancer-related to ensure routing to Evolent Oncology UM Program (Evolent) or Highmark as specified.
• Use code-to-program mapping for routing: follow the management designation shown next to each listed code when submitting PA/UM requests.

J-code-based UM assignment

Certain injectable specialty and oncology drugs are assigned to a specific UM program. For drugs listed with J- or Q-codes, providers must include the drug name and the exact HCPCS/J-/Q-code on the prior authorization or UM submission. Management responsibility often depends on diagnosis (Evolent for most cancer diagnoses; Highmark for non-oncology or other specialty assignments).

• J-code-based UM assignment: prior authorization/UM management is designated per listed J/Q codes and associated drug names; include the J-/Q-code and drug name on the request.
• Include specific drug and J-code information: list the exact drug and corresponding J-/Q-code on PA/UM requests.
• Include correct J-code and drug name to ensure accurate routing and adjudication.
• Submit correct code and site-of-care when applicable (site-of-care designations are shown for some oncology/site-of-care drugs).
• Use specific J-/Q-code for routing: management assignment (Evolent vs Highmark) is determined by the code and diagnosis.

MRI/MRA prior authorization routing

Prior authorization is required for many MRI/MRA/QMR services designated as Highmark Advanced Imaging (some are Gold Card Eligible). When requesting prior authorization for MRI/MRA/QMR procedures, reference the exact CPT/HCPCS/QMR code and route the request to Highmark Advanced Imaging as indicated.

• MRI/MRA prior authorization routing: many MRI and MRA CPT/HCPCS codes (for example 70549, 70551, 73718–73723, 74181–74183, 0610T–0612T, S8037, S8042) are designated Highmark Advanced Imaging.
• QMR codes (0649T, 0697T, 0698T) and other quantitative MRI codes are routed to Highmark Advanced Imaging.
• Gold Card Eligible: some advanced imaging codes are marked Gold Card Eligible — follow plan-specific Gold Card rules where applicable.

Prior authorization required for select therapy codes

Certain therapy and rehabilitation codes require prior authorization when routed to Highmark Physical Medicine/Highmark Physical. Include the therapy CPT code(s) and relevant clinical rationale when submitting PA/UM requests.

• Prior authorization required for select therapy codes effective 2/1/2020: OT codes 97129, 97130 and physical/therapy codes 97139, 97164 require prior authorization.
• Physical Medicine routing: these therapy codes are managed by Highmark Physical Medicine / Highmark Physical.
• When submitting UM requests for therapy codes, include the primary procedure code, therapy code(s), clinical rationale, and number of units/sessions.

Prior authorization routing and required codes

Certain device, powered vehicle, and accessory codes are managed by Highmark Management Services and require the proper procedure or supply code on UM/PA submissions. Include model/brand details when applicable.

• Each listed powered vehicle and accessory code (for example E1230, E1239, E2298, E2324, E2327, K0011, K0012, K0014, K0098, K0800–K0899, K0884–K0891, K0898–K0899) is managed by Highmark Management Services.
• Required coding on UM requests: include the applicable HCPCS/CPT/L-code (e.g., K0884, K0885, L1840, L3971, L6647, 0648T, 0649T, 0697T, 0698T, etc.) and device model/brand when requested.
• Coding documentation guidance: for QMR/QMR-related and reconstructive/cosmetic codes, include the primary procedure, clinical rationale, and any QMR code details on the request.

Program assignment and routing impact

Management assignment affects authorization routing and may impact timeliness of review. Services in the Evolent Oncology UM Program are managed by Evolent for most cancer diagnoses and by Highmark for other diagnoses; submitting to the wrong manager can delay or jeopardize authorization.

• Program routing for oncology vs non-oncology diagnoses: for items listed under the Evolent Oncology UM Program, indicate whether the diagnosis is cancer-related — Evolent manages most cancer diagnoses; Highmark manages non-cancer diagnoses.
• Management routing affects authorization: incorrect routing (e.g., sending an oncology cancer diagnosis case to Highmark instead of Evolent) may cause delayed review or denial risk.
• When in doubt, include the diagnosis and the specific code on the request to ensure correct routing to Evolent or Highmark.

What to include on UM/PA requests

When submitting prior authorization or UM requests: include the exact CPT/HCPCS/J-/Q-code, the associated drug name (for injectables), the member’s diagnosis, the site of care (if applicable), and the clinical rationale. This ensures the request is routed to the correct program (Evolent Oncology UM Program, Highmark Management Services, Highmark Advanced Imaging, Highmark Specialty, or Highmark Site of Care) and reduces the risk of delays or denials.

• Code-specific routing requirement: prior authorization or UM submissions must reference the exact procedure or HCPCS/J-/Q-code to route the service to the designated manager.
• Include correct J-code and drug name and submit correct code and site-of-care when applicable.
• Use code-to-program mapping and indicate the diagnosis (oncology vs non-oncology) to direct the request to Evolent or the appropriate Highmark program.