Highmark Blueshield Neny Coverage Criteria
Latest Highmark Blueshield Neny coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Delaware annual behavioral health well check coverage criteriaDefines coverage and reimbursement requirements for an annual behavioral health well check for Delaware members, including provider qualifications, required components of the visit, and mandated CPT reimbursement; applies to fully insured and certain state and Medicaid plans in Delaware.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Diabetes Management Program (Virtual Diabetes Care) - Coverage CriteriaDefines Highmark's virtual diabetes care programs (Verily Me for Type 1 and Onduo for Type 2), who is eligible, services offered, and exclusions for members covered under specified Highmark products.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyAcute Inpatient Rehabilitation Admission Request Form — Coverage CriteriaThis document is the Highmark Blue Shield acute inpatient rehabilitation admission request form and instructions for providers to submit required clinical, functional, and discharge information to request initial or continued inpatient rehab coverage for members.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyAddyi (flibanserin) prior authorization and reauthorization formThis document is a prior authorization and reauthorization request form for Addyi (flibanserin) used to treat hypoactive sexual desire disorder (HSDD) in premenopausal females. It governs requirements providers must submit to Highmark BlueShield for coverage consideration.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyAdvance Directives — Coverage CriteriaThis policy governs offering and documenting advance directives for patients (routinely for those aged 65 and older and upon request for younger patients) and specifies which life-sustaining treatments may be addressed. It applies to clinical staff responsible for patient care and medical record documentation.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyArmodafinil (Nuvigil) — Prior Authorization Coverage Criteria for Sleep DisordersForm and criteria governing prior authorization requests for armodafinil (Nuvigil) for sleep disorders (narcolepsy, obstructive sleep apnea, shift-work sleep disorder) submitted to Highmark BlueShield (Northeastern NY payer network). Affects prescribing providers requesting coverage for these medications.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyCertificate of Medical Necessity (CMN) for Oxygen Therapy — Coverage CriteriaThis document is a CMN form that governs documentation and clinical data required to establish medical necessity for home oxygen therapy for patients, intended for providers ordering oxygen equipment and services.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyCertificate of Medical Necessity (CMN) for Seat Lift MechanismThis document is the CMN form and associated criteria used to establish medical necessity for a seat lift mechanism (lift chair) for Highmark BlueShield members; it governs documentation and clinical conditions required from ordering providers.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyCertificate of Medical Necessity for Insulin Pump — Coverage CriteriaForm and criteria for documenting medical necessity for insulin pump coverage for Medicare Advantage members; used by providers to support coverage decisions. Affects providers requesting pump coverage and Medicare Advantage enrollees.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyDetailed Notice of Discharge - Coverage CriteriaExplains to a patient why their inpatient hospital services are being ended and provides information about requesting an independent review by the Quality Improvement Organization (QIO). Applies to Medicare beneficiaries and those in Medicare managed care plans affected by a discharge decision.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyDupixent (dupilumab) prior authorization request form coverage criteriaForm and clinical intake questions used to request prior authorization for Dupixent (dupilumab) for multiple indications (atopic dermatitis, asthma, eosinophilic esophagitis, chronic rhinosinusitis with nasal polyposis, prurigo nodularis, COPD, chronic spontaneous urticaria). Affects prescribing providers and prior authorization reviewers for Highmark BlueShield NE/NY membership.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyEmgality (galcanezumab) prior authorization form for migraine/cluster headache prophylaxisA medication prior authorization form used by Highmark BlueShield for Emgality (galcanezumab) to document clinical indications, prior therapeutic failures/intolerance, dosing (including loading dose), concurrent CGRP use, and reauthorization effectiveness criteria for episodic migraine, chronic migraine, and episodic cluster headache.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyEvolocumab (Repatha) prior authorization coverage criteriaDefines the information and clinical criteria required for prior authorization of Evolocumab (Repatha) injections for members of Highmark BlueShield regions. Affects prescribing providers (cardiologists, lipid specialists, endocrinologists, PCPs) and pharmacy/benefit reviewers processing Repatha requests.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyHemophilia / Bleeding Disorder Medication Prior Authorization Form Coverage CriteriaCovers prior authorization documentation and clinical criteria required for authorization of hemophilia and bleeding-disorder therapies for Highmark Blue Shield members; affects prescribing providers requesting coverage for factor products and related medications.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyIn Vitro Fertilization (IVF) Coverage CriteriaDefines medical indications and prior authorization information for IVF coverage for Highmark BlueCross BlueShield Delaware members; intended for providers requesting authorization and documenting infertility diagnoses and prior treatments.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyMedication Prior Authorization Form - Coverage CriteriaForm and instructions to request prior authorization for prescription medications for Highmark members; used by prescribing providers to submit clinical and administrative information required for authorization decisions.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient ABA Authorization Request Form — Coverage CriteriaThis document is an outpatient behavioral health Applied Behavior Analysis (ABA) authorization request form used by providers to request initial or continued ABA services from Highmark BlueShield NENY. It affects providers submitting ABA prior authorization and supporting documentation for members in the plan.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Behavioral Health ABA Request Form Coverage CriteriaThis document is an authorization/request form used by providers to request initial or continued outpatient Applied Behavior Analysis (ABA) services for members; it collects diagnostic, provider, clinical, assessment, and billing information required for authorization processing.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Botulinum Toxin Injectable Request Form — Coverage CriteriaForm and criteria for requesting outpatient botulinum toxin (e.g., Botox, Dysport) under the medical benefit for Highmark BlueShield NENY members; used by ordering providers and facilities to document clinical information for authorization decisions.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Botulinum Toxin Injectable Request Form — Coverage CriteriaForm and documentation requirements for outpatient medical benefit requests for botulinum toxin injections (e.g., Botox, Dysport, Myobloc, Xeomin) used by providers submitting to Highmark BlueShield NENY. Affects ordering/requesting physicians, administering providers, and facility billing for members with migraine, hyperhidrosis, or other indications.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Chemotherapy Aloxi (palonosetron) Request Form — Coverage CriteriaA form and checklist used by providers to request outpatient Aloxi (palonosetron) under the medical benefit for chemotherapy-associated or post-operative nausea/vomiting; intended for ordering/attending providers and servicing facilities submitting authorization information to Highmark. Affects providers submitting prior authorization requests for Aloxi.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Leqvio (inclisiran) Injectable Request Form — Coverage CriteriaForm and requirements to request outpatient medical benefit coverage for Leqvio (inclisiran) for Highmark members; used by ordering providers and facilities to document clinical indications and prior therapies. Affects providers submitting Leqvio requests for Highmark Blueshield NENY members.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Medical Injectable Granulocyte Colony-Stimulating Factors (G-CSF) — Coverage CriteriaForm and criteria for prior authorization of outpatient medical benefit injectable G-CSF products for members (prevention of chemotherapy-induced febrile neutropenia and related uses). Affects providers requesting coverage for listed G-CSF agents.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Medical Injectable Granulocyte Colony-Stimulating Factors (pegfilgrastim, eflapegrastim) Coverage CriteriaDefines outpatient medical benefit authorization and coverage considerations for pegfilgrastim and eflapegrastim products (including biosimilars and brand variants) for prevention of chemotherapy-induced febrile neutropenia and related indications for Highmark members.All Highmark Blueshield Neny updates
- Coverage CriteriaClinical/Medical PolicyOutpatient Ocrevus (ocrelizumab) Authorization — Coverage CriteriaThis form governs prior authorization requests for outpatient administration of Ocrevus (ocrelizumab) for members covered by Highmark BlueShield entities; it is used by ordering providers/site of care to request authorization and document clinical information.All Highmark Blueshield Neny updates
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Search Highmark Blueshield Neny coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
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Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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