Avalon to Manage Post-Service Reviews for Non-Molecular Lab Claims

Effective Feb. 1, 2027, Highmark will engage Avalon Healthcare Solutions to assist with post-service reviews of non-molecular laboratory claims for your Highmark Commercial, Medicare Advantage, and Affordable Care Act (ACA) patients in Delaware, New York, Pennsylvania, and West Virginia.

Avalon’s Laboratory Benefit Management (LBM) program will ensure coding accuracy during the post-service prepayment process. This program applies to routine outpatient laboratory testing performed across all places of service, including in-office, hospital outpatient, and independent laboratory settings.

Exclusions: Laboratory services, tests, and procedures provided in emergency rooms, hospital observation units, and inpatient settings are excluded from this program.

What You Need to Know

Avalon’s LBM is an evidence-based approach that helps align lab testing with current scientific evidence to improve patient outcomes and manage healthcare costs.

Avalon has a dedicated landing page for Highmark providers where you can view laboratory operational policies.

Benefits of the Claim Review Process

The benefits of implementing LBM for non-molecular laboratory claims include:

• Prompt review and approval recommendations for correct non-molecular lab claims.
• Coding inaccuracies will be caught sooner, reducing claims adjustments and provider refunds to Highmark.
• Decreased administrative time for researching and adjusting claims that have already been processed and paid.

Note: eviCore was previously conducting prepayment reviews on non-molecular lab claims submitted by providers in Delaware, Pennsylvania, and West Virginia. Those reviews were discontinued on Sept. 30, 2026.

What You Need to Do

• Continue following Highmark's existing claims submission processes.
• Review applicable laboratory operational policies before ordering or performing testing.
• Use accurate diagnosis and procedure coding.
• Stay informed of policy updates published by Highmark.

Keep an eye on the Provider Resource Center (PRC) and join our mailing list to receive updates on Highmark policy and program changes.