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Pre-Certification

The Medical Plan requires pre-certification review and approval before certain healthcare services will be covered. You, or your physician’s office, should start the pre-certification process as soon as your physician recommends a service requiring this approval.

Overview

  • The back of your medical ID card lists the tests, procedures, and admissions requiring advance approval. These tests, procedures, and admissions are listed in greater detail below (see Services Requiring Pre-Certification).
  • Allow up to 10 days for pre-certification of a non-emergency service.
  • To start pre-certification, have your physician call Highmark at 888-835-2959. Use this number for those medical/surgical and behavioral health/substance use disorder services that require advance approval.
  • All emergency hospitalization services, whether for medical/surgical or behavioral health/substance use disorder treatment, must be pre-certified within 48 hours of admission. Benefits are payable only if pre-certification requirements are met.

Services Requiring Pre-Certification

You must pre-certify with Highmark the following:

  • hospital admission for nonemergency medical or surgical treatment, including maternity
  • bariatric or other weight-loss surgery
  • scheduled outpatient imaging, excluding X-rays and ultrasounds
  • scheduled nuclear stress tests
  • all facility-based treatment for mental health or substance use disorders*
  • biofeedback and electroshock therapies
  • prescriptions for medical injectable drugs

If You Do Not Pre-Certify

If you do not pre-certify a service that requires advance approval and then submit a claim, the plan’s utilization review consultant, Highmark, will review it retroactively. If Highmark determines the service was not appropriate and medically necessary, your claim will be denied and no benefits paid.

*To find a network facility and to maximize your coverage, contact Highmark to determine medical necessity and to pre-certify the proper level of care.