CurrentHighmark DelawarePolicy N/A

Outpatient Chemotherapy Request Form (Medical Benefit Only)

Form and instructions for providers to request outpatient chemotherapy services under the medical benefit for Highmark Delaware members. Collects patient, provider, diagnosis, regimen, line of therapy, prior treatment details, and supporting documentation for utilization management review.

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Chemotherapy Request Form (Medical Benefit Only)

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the chemotherapy request form to 833-581-1861 with required patient, provider, diagnosis, regimen, line of therapy, prior treatment details, and attach pertinent clinical information to initiate utilization management review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Primary document: chemotherapy request form

833-581-1861Fax number to submit form

HCPCS J-codes & ICD-10Clinical coding fields requested on form

Information Required for Chemotherapy Request

Information required for chemotherapy request

Policy Summary

PayerHighmark Delaware

PolicyOutpatient Chemotherapy Request Form (Medical Benefit Only)

Policy CodePolicy N/A

Change TypeInformational

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Member identifying information (name, date of birth, member ID/UMI)
Payer type indicated (Medicare or Commercial) checkbox
Ordering provider/contact information including name, NPI, address, phone, fax
Requested start date of service
HCPCS J-code(s) for chemotherapy drug(s)
ICD-10 diagnosis code(s)
Cancer type including histology and stage
Chemotherapy regimen
Line of therapy (first, second, subsequent)
History of previous therapies, including progression/relapse status
Form requests attachment; checkbox for Attached: YES/NO
Pertinent clinical information attached (radiology, pathology, clinic notes, labs)

What Providers Must Do

Prior Authorization

Submit outpatient chemotherapy request

Providers must complete and fax the Outpatient Chemotherapy Request Form to 833-581-1861 to initiate utilization management review. The form must include required patient and provider identifying information, diagnosis (ICD-10) and HCPCS J‑code(s), chemotherapy regimen, line of therapy, and history of prior therapies; attach pertinent clinical information as indicated on the form.

HCPCS J-codes
ICD-10

Documentation Required

Attach supporting clinical documentation

Attach all pertinent clinical information as indicated on the form (for example, pathology, staging, prior treatment records, and documentation of progression or relapse) and indicate attachment by selecting the Attached: YES checkbox on the form.

Denial Risk

Incomplete submission risk

Incomplete submissions — including missing required fields or missing attachments — may delay review or result in denial of the request.

Purpose and Scope

This document is an administrative request form used by providers to request outpatient chemotherapy services under Highmark Delaware's medical benefit. It collects clinical and administrative data to support prior authorization and utilization management decisions, including member and ordering provider details, requested start date, chemotherapy drug HCPCS J-code(s), and ICD-10 diagnosis code(s).

The form is intended for providers to request outpatient chemotherapy services for Highmark Delaware members and gathers information required for utilization management review: patient identifiers (name, date of birth, member ID/UMI); payer type checkbox (Medicare or Commercial); ordering provider contact and NPI; requested start date of service; cancer type with histology and stage; chemotherapy regimen and line of therapy (first, second, subsequent); history of prior therapies including progression/relapse; and indication whether pertinent clinical information (radiology, pathology, clinic notes, labs) is attached via the Attached: YES/NO checkbox. Providers must verify member eligibility and benefits through the health plan as noted on the form.

OpenPayer

Outpatient Chemotherapy Request Form (Medical Benefit Only)

Information Required for Chemotherapy Request

Requested Coding Fields on Form

What Providers Must Do

Purpose and Scope

Defined Terms

Policy Update Changes

At-a-glance Submission Details

HCPCS J-codes	Place to list chemotherapy drug HCPCS J-codes (specific codes not pre-filled on form)
ICD-10	Place to list diagnosis ICD-10 code(s) corresponding to cancer diagnosis