New and Updated Reimbursement Policies

Highmark regularly issues new or updated reimbursement policies. Keep an eye on this newsletter and the Provider Resource Center (PRC) homepage for announcements regarding upcoming policy changes. As specific policy changes go into effect, the updated policies can be found on the Reimbursement Policy page of the PRC.

Below is a list of recent and upcoming updates to Reimbursement Policies (RPs):


January 1, 2024

MRP-006 Wrong Surgery
Effective December 31, 2023, this policy is being archived. The direction of this policy will be merged into a new version of RP-036 (see below), which takes effect January 1, 2024.

RP-019N Drugs and Biologicals
Effective January 1, 2024, Highmark will move the New York reimbursement direction in RP-019N to the reimbursement direction for Delaware, Pennsylvania, and West Virginia that is currently outlined in the policy. This change will streamline and standardize how the plan reimburses for these services across all regions, and reduce administrative costs associated with maintaining different reimbursement methods.

To view this reimbursement policy, access the PRC via the provider portal either Availity® or NaviNet®. Once redirected to the PRC from the provider portal, select CLAIMS, PAYMENT & REIMBURSEMENT in the left-hand menu and then click Reimbursement Policy.

RP-036 Preventable Serious Adverse Events
This policy will be updated to include a Medicare Advantage section containing direction merged from MRP-006 (see above).

RP-057 Evaluation & Management Services
The note included under “Level based on Medical Decision Making (MDM)” will be updated.

RP-073 Performance Measurement
Several New York Medicare Advantage exception codes will be removed.

January 15, 2024

RP-037 Emergency Evaluation and Management Coding Guidelines
Outpatient surgery will be removed from the exclusion criteria.

April 1, 2024

RP-006 Multiple Endoscopy Procedures
New York Commercial products are being applied to this policy direction effective April 1, 2024.

RP-034 Prolonged Detention or Critical Care
Code 93598 will be added to the “Prolonged Detention or Critical Care” section of this policy.