New and Updated Reimbursement Policies
Highmark regularly issues new or updated reimbursement policies. Keep an eye on the Provider Resource Center (PRC) homepage for Special Bulletins announcing upcoming policy changes and the Reimbursement Policy page for specific policy updates.
Below is a list of upcoming and recently updated Reimbursement Policies (RP) and Medicare Advantage Reimbursement Policies (MRP):
Medicare Advantage-Related Changes – All Regions
- RP-033 Anesthesia Services This policy has been updated to remove a reference to Medicare Advantage (MA) medical policy N-118.
Medicare Advantage-Related Changes – PA, WV, and DE Regions
- RP-005 Modifiers 54, 55, and 56
Below is a summary of the MA changes effective September 1, 2022, for the Pennsylvania, West Virginia, and Delaware regions.
- Modifier 54 – The Plan will reimburse claim lines at the code specific pre-op and intra-op percentages (of the approved allowance) as defined on the Medicare Physician Fee Schedule (MPFS).
- Modifier 55 – The Plan will reimburse claim lines at the code specific post-op percentages (of the approved allowance) as defined on the MPFS multiplied by the percentage of the post-op period for which the physician provided care.
- Modifier 56 – The Plan does not apply a reduction.
- RP-064 Government Supplied Vaccinations and Antibody Treatments The following two changes were recently published:
- Effective January 24, 2022, the Federal Drug Administration (FDA) has rescinded the emergency use authorization for the monoclonal antibody therapy Casirivimab and Imdevimab, identified by codes Q0240, Q0243, Q0244, as well as the administration of that service identified by codes M0240, M0241 and M0244. Therefore, for dates of service on and after January 24, 2022, these codes will no longer be eligible for reimbursement.
- The American Medical Association has released new codes 91312, 91313, 0124A, 0134A, which are retroactively effective August 31, 2022, and are being added to the policy. Effective January 25, 2022, the FDA has rescinded the emergency use authorization for the monoclonal antibody therapy Bamlanivimab and Etesevimab, identified by code Q0245, as well as codes M0245 and M0246 for administration of that service. Therefore, on and after January 25, 2022, those three codes are no longer eligible for reimbursement.
To access Highmark reimbursement policy bulletins, select CLAIMS, PAYMENT & REIMBURSEMENT
from the Provider Resource Center main menu, and then click on REIMBURSEMENT POLICY