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 Dec. 31, 2023, this policy was archived. The direction of this policy was merged into a new version of RP-036 (see below), which went into effect Jan. 1, 2024.

RP-007 Multiple Procedure Payment Reduction (MPPR) for Certain Diagnostic Imaging Procedures
Codes 0826T and 0865T were added.

RP-011 Procedure Codes Not Applicable to Commercial Products
Code G0137 was added.

RP-019N Drugs and Biologicals
Effective January 1, 2024, Highmark moved the New York reimbursement direction in RP-019N to the reimbursement direction for Delaware, Pennsylvania, and West Virginia that is outlined in the policy. This change streamlines and standardizes how the plan reimburses for these services across all regions, and reduces 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 was updated to include a Medicare Advantage section containing direction merged from MRP-006 (see above).

RP-041 Services Not Separately Reimbursed
Code G2211 was removed and is now a separately payable service when eligible.

RP-042 Global Surgery and Subsequent Services
Codes 0784T, 0785T, 0786T, 0787T, 0790T, 0816T – 0819T, 0823T – 0825T, and 0861T – 0863T were added to the global YYY codes sections for Medicare Advantage and Commercial.

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

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

January 15, 2024

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

RP-057 Evaluation & Management Services
The RP-041 policy cross reference note for code G2211 was removed.


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.

April 29, 2024

RP-041 Services Not Separately Reimbursed
Code 76140 will be added and will no longer be a separately reimbursed service.

May 1, 2024

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

RP-026 Portable Radiography and ECG Services – Modifiers UN, UP, UQ, UR, US
Direction for “U” modifier reductions reported with code R0075 will be made applicable for Commercial.