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 recently updated and upcoming Reimbursement Policies (RPs):

RECENTLY UPDATED

August 7

RP-032 Pain Management
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-034 Prolonged Detention or Critical Care
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-041 Services Not Separately Reimbursed
This policy was made applicable to facility (UB) claims.


August 14

RP-035 Correct Coding Guidelines
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-052 Surgical Team
This policy was reviewed as part of our standard review process. No changes in direction were made.


UPCOMING

RP-010 Update

RP-010 Incident To Billing Services and Advanced Practice Provider Reductions

For West Virginia: West Virginia was inadvertently checked as an applicable Commercial market in the current version of RP-010. This will be corrected in the updated policy. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers who have been enumerated and bill using their own provider ID.*

For Pennsylvania: Incident To services for Commercial products will no longer be recognized, effective January 1, 2024. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers.*

For Delaware: Only non-Primary Care Physician (PCP) Incident To services will no longer be applicable to the policy, effective January 1, 2024. PCP Incident To services will still be covered. Highmark will also continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers.*

For New York: New York was inadvertently checked as an applicable Commercial market in the current version of RP-010. This will be corrected in the updated policy. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers who have been enumerated and bill using their own provider ID.*

*Direction for continued reimbursement for Mid-Level Practitioners and Advanced Practice Providers will be published in a new policy, RP-068 (see NEW: RP-068 further down in this article), effective on September 25, 2023.


August 31 (Effective September 1):

RP-019N Drugs and Biologicals
An updated version of this policy will be available for review on the PRC on August 31, 2023, and will be effective beginning September 1, 2023. Drug tiering is being eliminated for Delaware, Pennsylvania, and West Virginia. To access this reimbursement policy, log into NaviNet® and select Resource Center from the left menu. Once redirected to the PRC, select CLAIMS, PAYMENT & REIMBURSEMENT in the left menu and then click Reimbursement Policy.


September 25

NEW: RP-068 Mid-Level Practitioners and Advanced Practice Providers
Highmark has created RP-068 to provide direction on reimbursement for Mid-Level Practitioners and Advanced Practice Providers. (NOTE: This policy will be available on the PRC on September 25, 2023.)


October 30

RP-026 Portable Radiography and ECG Services – Modifiers UN, UP, UQ, UR, US
This policy will be made applicable to Medicare Advantage. Additional direction will be added for modifiers UN, UP, UQ, UR, and US when submitted with code R0075 (a transportation service code). These modifiers are also required to be included on all related claims, and the Commercial section will be updated with direction to reflect this requirement.


 

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