Highmark Behavioral Health Billing in Pennsylvania: Prior Auth, Telehealth and Credentialing
Highmark behavioral health billing follows its own rules, and those rules do not carry over to the other Pennsylvania Blue companies. This guide covers Highmark Blue Cross Blue Shield and Highmark Blue Shield. If your patient carries an Independence Blue Cross or Capital Blue Cross card, use our Pennsylvania Blue Cross guide instead.
Which part of Pennsylvania does Highmark cover?
Highmark’s own site says it serves “the 42 counties of western, north central and northeastern Pennsylvania” (Highmark, our businesses). Always read the member ID card, and keep our Pennsylvania insurance contact numbers handy. A practice near a service-area line can see members from more than one Blue company.
How does Highmark behavioral health billing connect to care management?
Highmark Behavioral Health Services provides behavioral health medical management for members in Highmark programs, according to the Highmark provider manual. The manual also says behavioral health benefits vary by product and group, so verify benefits before you treat (Highmark manual, behavioral health unit, page updated 2026-08-27).
Check eligibility in Availity, the shared portal Highmark uses for eligibility, claim status and authorizations. Our insurance verification page explains what to confirm each time. Verify benefits first, because Highmark behavioral health billing depends on the member’s product and group.
Which outpatient behavioral health services need prior authorization?
On March 1, 2026, Highmark added 19 codes to its outpatient prior authorization list for four services. The manual says the requirement does not currently apply to the Federal Employee Program or Medicare.
| Service | Prior authorization per Highmark manual |
|---|---|
| Applied behavior analysis (ABA) | On the March 1, 2026 list |
| Intensive outpatient programming (IOP) | On the March 1, 2026 list |
| Partial hospitalization programming (PHP) | On the March 1, 2026 list |
| Transcranial magnetic stimulation (TMS) | On the March 1, 2026 list |
| Inpatient behavioral health | Required for most Highmark products; submit through Availity |
| Emergency services | Not required, but an admission that follows emergency care is |
The manual page does not list routine outpatient psychotherapy or medication management among the services that need authorization. Still, confirm in Availity for each member, because benefits vary by group. For more on how authorization terms work, see the authorization terms glossary.
What place of service and modifier does Highmark want for telehealth therapy?
Highmark’s reimbursement policy RP-046 sets the rule. Use place of service (POS) 02 when the patient is outside the home and POS 10 when the patient is at home. For audio-only mental health visits, append modifier FQ or 93. Highmark limits audio-only to established patients at home who cannot or will not use two-way audio and video, and the record must say the visit was audio-only (Highmark RP-046, version effective 2026-09-01).
RP-046 also lists modifiers GT, 93 and 95, and says they must be appended on outpatient facility claims. Read the professional-claim section before you submit. Our guide to telehealth place of service and modifiers 93 and 95 and the telehealth billing glossary give the plain-English version. Get the telehealth coding right before you submit any Highmark behavioral health billing.
How do I get credentialed with Highmark?
Highmark credentialing starts with a current CAQH profile. CAQH is the shared provider-data database most payers pull from. Highmark’s professional credentialing page lists four steps (Highmark professional credentialing):
- Create or update your CAQH ProView profile and authorize Highmark to see it.
- Submit the credentialing request through the CertifyOS provider portal.
- Affiliate with a billing practice (an assignment account).
- Return the signed group contract.
Highmark states plainly that “credentialing approval alone does not authorize billing.” Wait for the welcome letter that confirms your participation date. Our in-network versus out-of-network guide helps you decide whether to join at all.
Two network rules matter for specific license types. A Highmark bulletin says psychologists are eligible for the Medicare Advantage network only with a PhD, PsyD or EdD, effective May 19, 2025. It also changes which accrediting bodies Highmark accepts for behavioral health organizational providers, which matters if you bill as a group or facility (Highmark credentialing update).
What should psychiatrists check?
Psychiatrists bill E/M visits and sometimes add psychotherapy add-on codes. The Highmark pages reviewed here do not spell out E/M or add-on code edits, so check the reimbursement policy list in Availity for E/M and add-on edits before you bill. Our CPT and E/M code guide is a good starting point, and electronic claims submission covers clean-claim habits. Prescribers should pair these checks with the rest of their Highmark behavioral health billing workflow.
Three mistakes to avoid with Highmark
- Using Highmark’s rules for another Blue company. Independence Blue Cross and Capital Blue Cross publish their own policies. Match the card to the guide, and see how BlueCard routes out-of-state Blue claims.
- Skipping the benefits check. Highmark says behavioral health benefits vary by product and group. A quick Availity check before the first session beats a denial three weeks later.
- Coding telehealth from memory. Place of service and modifier rules sit in a policy that was re-issued with a September 1, 2026 effective version. Read the current text, not last year’s cheat sheet.
Avoiding these three errors makes Highmark behavioral health billing much smoother.
Frequently asked questions
Does Highmark cover all of Pennsylvania?
No. Highmark says it serves 42 counties in western, north central and northeastern Pennsylvania. Other Blue companies serve other regions.
Is prior authorization needed for 90837?
Highmark’s manual page does not list psychotherapy codes among the outpatient services added to the authorization list on March 1, 2026. Confirm each member’s benefits in Availity.
Do I need a separate Highmark contract after credentialing?
Yes. Highmark’s process includes a signed group contract, and approval alone does not authorize billing.
Which telehealth modifier does Highmark use for audio-only mental health visits?
FQ or 93, per RP-046, for established patients at home who cannot or will not use two-way video.
Where MCM South Medical Billing Service Works
MCM South Medical Billing Service, LLC works exclusively with mental and behavioral health practices, including psychotherapists and psychiatrists, and bills out-of-network claims. We offer our services to practices in Pennsylvania, and we also work with practices in Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. If you want to talk through your own billing, you can request a free consultation.
If you practice in Pennsylvania and want help with payer rules, you can request a free consultation. Questions? Our mental health billing FAQ answers the common ones.
