Short Takes: ASAM 4th Edition and Respiratory Panels Reimbursement

Quarterly Fee Schedules

The standard professional quarterly fee schedules were published during the week of April 14, 2024. To view them on the Provider Resource Center (PRC), log into Availity®, go to Payer Spaces, and then select Provider Resource Center under Applications. Once you arrive at the PRC, choose CLAIMS, PAYMENT & REIMBURSEMENT from the left menu and click Fee Schedule Information.

Reimbursement Changes for Respiratory Panels that Test for 5 or More Pathogens

Highmark is committed to ensuring members receive appropriate care based on well-established, evidence-based clinical guidelines that result in better outcomes and lower costs. To promote medically necessary and cost-efficient patient care, Highmark is reducing the reimbursement for respiratory pathogen panels that check for the presence of 5 or more pathogens, effective July 1, 2024.

Respiratory pathogen panels that test for fewer than 5 pathogens are effective for detecting three of the most common respiratory infections — COVID-19, respiratory syncytial virus (RSV), and influenza — while also being less expensive. For more information, click here.

ASAM 4th Edition to be Implemented on July 1

Effective July 1, 2024, Highmark will transition from American Society of Addiction Medicine (ASAM) 3rd Edition to ASAM 4th Edition. Highmark uses ASAM criteria to review authorization requests for substance abuse services.

To learn more about the ASAM 4th Edition, go here.

Quick Claims Functionality in Availity

Professional providers who use Availity Essentials for claim submission now have access to the Quick Claims functionality for Highmark members. Quick Claims allows providers to create templates that pre-populate certain fields when submitting a CMS-1500 claim. This will save time for providers who routinely submit claims for the same patient or same service each week or each month. For more information, see the recent Special Bulletin.