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-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-044 Medical Therapy Management Services
The Public Health Emergency (PHE) exception note will be removed from this policy.

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

RP-072 Injection and Infusion Services
Effective January 1, 2024, Highmark will be applying a system enhancement to identify when chemotherapy administration codes are billed and enforce the direction currently defined on RP-072. For providers, this enhancement will reduce administrative costs associated with claim audits and adjustments by supporting the correct adjudication of claims before the finalization of initial claim processing.

In addition, the description for code 96361 will be updated.

January 15, 2024

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

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.