A newsletter for the Highmark Blue Shield providers in central Pennsylvania, the Lehigh Valley, northeastern Pennsylvania and southeastern Pennsylvania
Issue 12, December 2023
New and Updated Reimbursement PoliciesHighmark 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):
MRP-006 Wrong Surgery
Effective December 31, 2023, this policy is being archived. The direction of this policy will be merged into a new version of RP-036 (see below), which takes effect January 1, 2024.
RP-010 Incident To Services
This policy will no longer be applicable to the Pennsylvania Commercial Market.
RP-036 Preventable Serious Adverse Events
This policy will be updated to include a Medicare Advantage section containing direction merged from MRP-006 (see above).
RP-057 Evaluation & Management Services
The note included under “Level based on Medical Decision Making (MDM)” will be updated.
RP-072 Injection and Infusion Services
Effective January 1, 2024, Highmark will be applying a system enhancement to identify when chemotherapy administration codes are billed and enforce the direction currently defined on RP-072. For providers, this enhancement will reduce administrative costs associated with claim audits and adjustments by supporting the correct adjudication of claims before the finalization of initial claim processing.
RP-037 Emergency Evaluation and Management Coding Guidelines
Outpatient surgery will be removed from the exclusion criteria.
RP-034 Prolonged Detention or Critical Care
Code 93598 will be added to the “Prolonged Detention or Critical Care” section of this policy.
