Reimbursement Policy

Highmark's reimbursement policies address claims reimbursement logic as opposed to clinical information, which is addressed on medical policy. Each reimbursement policy includes information pertaining to all Highmark markets as indicated in the header, with state specific variations indicated within the policy bulletin.

History versions of reimbursement policies are stored within the PDF files. Click the "View History" link on the first page of the policy to view previous versions.

* The policies on this page that have a policy end date are no longer applied in claims processing based on the policy end date. Please take note of the policy end date listed below and within the policy text.

Number Audience Subject Date Updated Policy End Date *
RP-001 Professional Assistant at Surgery Services


RP-002 Professional Co-Surgery 12/2017
RP-003 All Drug Wastage and Modifier JW 09/2018
RP-004 Professional Modifiers 52-53 12/2017
RP-005 Professional Modifiers 54-55 12/2017
RP-006 Professional Multiple Endoscopy Procedures 12/2017
RP-007 Professional Multiple Procedure Payment Reduction (MPPR) for Certain Diagnostic Imaging Procedures 12/2018
RP-008 All X-rays Using Film, Computed Radiography and Computed Tomography 02/2018
RP-009 Professional Modifiers 25, 59, XE, XP, XS and XU 07/2018
RP-010 Professional Applied Behavior Analysis MUE Limits 12/31/17
RP-011 Professional Procedure Codes Not Applicable to Commercial Products 12/2018
RP-012 Professional Rigid Immobilization 10/2017
RP-013 Professional Electrocardiogram and Medical Imaging Interpretation 12/2017
RP-014 Professional Multiple Surgical Procedures 12/2017
RP-015 Professional Professional and Technical Components for Applicable Services 01/2019
RP-016 Professional Physician Laboratory and Pathology Services 12/2017
RP-017 All Evocative or Suppression Testing Panels 10/2017
RP-018 Professional Myocardial Perfusion SPECT Imaging 12/2017
RP-020 All Preventive Medicine and Office or Outpatient Evaluation and Management Services  11/2018
RP-021 All Annual Gynecological and Rectal Exams 01/2018
RP-022 Professional Repeat Surgical Procedures 12/2018
RP-023 Professional Newborn Care, Obstetrical Delivery, Antepartum and Postpartum Care and Associated Services 01/2018
RP-024 Professional Eye Procedures Done in Stages or Sessions 01/2018
RP-025 All Implantation of Subcutaneous Intravascular Catheter 01/2018
RP-026 All Portable Radiography and ECG Services 01/2018
RP-027 All Hemodialysis and Peritoneal Dialysis 12/2018
RP-028 Professional Insertion and Removal of Tympanic Ventilation Tubes 03/2018
RP-029 Professional Surgical Techniques 12/2018
RP-030 Professional Insertion of Tissue Expanders 03/2018
RP-031 Professional Fractures and Dislocations 03/2018
RP-032 Professional Pain Management 12/2018
RP-033 Professional Anesthesia Services 12/2018
RP-034 Professional Prolonged Detention or Critical Care 05/2018
RP-035 All  Correct Coding Guidelines 08/2018
RP-036 Professional Preventable Serious Adverse Events 06/2018
RP-037 Facility Emergency Evaluation and Management Coding Guidelines 08/2018
RP-038 All Out of Network Services 08/2018
RP-039 All Outpatient Services Prior to An Inpatient Admission 10/2018
RP-040 Facility Facility Routine Supplies and Services 09/2018
RP-041 Professional Services Not Separately Reimbursed 12/2018
RP-042 Professional Global Surgery and Subsequent Services 12/2018
RP-043 Professional Care Management 12/2018
RP-044 Professional BRCA Genetic Testing 12/31/18
RP-045 Professional Purchased Services 10/2018

Reimbursement policies are intended to reflect Highmark's coding & reimbursement guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update the reimbursement policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the reimbursement policies is prohibited; however, limited copying of reimbursement policies is permitted for individual use.
The five-digit numeric codes that appear on the reimbursement policies on this web site were obtained from the Physician's Current Procedural Terminology Manual, © American Medical Association.
Current Dental Terminology. © American Dental Association. All rights reserved.
Last updated on 1/11/2019


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