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):

Upcoming


Coding Changes

  • RP-011 Procedure Codes Not Applicable to Commercial Products Codes G0310, G0311, G0312, G0313, G0314, G0315, and A0021 are being added to this policy. An appendix B was created on the policy to clarify the codes that are not applicable to commercial products because they are Medicaid-specific.
  • RP-053 Gene and Cellular Therapy Effective October 1, 2022, code C9098 representing drug Ciltacabtagene Autoleucel, was replaced with new code Q2056.

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 – New York Regions

*NOTE: The above MRPs will be posted on the Provider Resource Center for Western New York on January 1, 2023—when they become applicable for this region.

  • RP-004 Modifiers 52-53 Modifier 52 – 50% reduction and Modifier 53 – 50% reduction will be applied for MA in New York.
  • RP-005 Modifiers 54, 55, and 56
    • Modifier 54 – Claim lines will be reimbursed at 70% of the approved allowance.
    • Modifier 55 – Claim lines will be reimbursed at 20% of the approved allowance.
    • Modifier 56 – Claim lines will be reimbursed at 10% of the approved allowance.
  • RP-049 Merit-Based Incentive Payment System (MIPS) for Out of Network Providers Changes were effective September 1, 2022, and applicable to the MA business in the New York regions only.
  • RP-067 Specific Service Daily Maximum Effective September 1, 2022, this policy is being updated to include New York MA as applicable to the direction already present in the New York section of the policy.
  • RP-071 Incremental Nursing Changes were effective September 1, 2022, and applicable to the MA business in the New York regions only.


Vaccine-Related

  • 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    • Effective January 24, 2022, the Federal Drug Administration (FDA) has rescinded the emergency use authorization for the monoclonal antibody therapy Casirivimab and Imdevimab, identified by codes Q0240, Q0243, Q0244, as well as the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.

 

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