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):
RP-037 Emergency Evaluation and Management Coding Guidelines
Policy is being updated to provide direction on the Plan’s analysis of evaluation and management codes for accuracy.
RP-019N Drugs and Biologicals
The policy is being updated with direction on the New York market’s reimbursement of Drugs and Biologicals. This tiered reimbursement structure has been in place for many years, and it is being documented in a policy for provider consumption. To access, log into NaviNet® and select Resource Center from the left menu. Once redirected to the Provider Resource Center, choose CLAIMS, PAYMENT & REIMBURSEMENT from the left menu then Reimbursement Policy.
RP-041 Services Not Separately Reimbursed
This policy is being updated for Commercial products to add codes 38204, 90889, 92605, 92606, 92618, 93740, and R0076. These codes will be considered not separately reimbursed and rejected as non-billable to the member.
RP-057 Evaluation and Management Services
The policy is being updated to align with recent changes to Centers for Medicare and Medicaid Services (CMS) guidance for selecting the level of a reported Evaluation and Management (E/M) service and the eligibility for E/M reimbursement based on the fulfillment of the required criteria. As of January 1, 2023, all Evaluation and Management services are now selected and scored based on medical decision-making (MDM) or time.
NEW: RP-075 Appropriate Use Criteria for Advanced Diagnostic Imaging
Highmark has created RP-075 to provide direction to practitioners on how to successfully increase the rate of advanced diagnostic imaging services based on Appropriate Use Criteria. For more information, click to read the Special Bulletin .
RP-008 X-rays Using Film, Computed Radiography and Computed Tomography: Modifiers FX, FY, CT
Policy is being updated to clarify direction for the Highmark Blue Cross Blue Shield of Western New York (BCBSWNY) and Highmark Blue Shield of Northeastern New York (BSNENY) regions.