Expanded List of Non-Specific Codes Subject to Additional Review

To ensure accurate claims processing and appropriate reimbursement for services, Highmark is expanding our review of claims submitted with non-specific CPT codes. This update will help maintain clinical standards and medical necessity.

Effective Dates for Expanded Review Implementation

• July 15, 2026 – Delaware, Pennsylvania, and West Virginia
• Aug. 15, 2026 – New York

What's Changing?

More than 100 non-specific codes will receive additional review beginning on the dates listed above.

Claims submitted with non-specific codes may require medical policy review and/or medical necessity review before a final decision is made.

What Are Non‑Specific Procedure Codes?

Non‑specific CPT codes are used when a more precise code doesn’t exist for a service. These codes are described variously as not otherwise classified, not elsewhere classified, not specific, or not specified.

Additional review helps ensure services are medically necessary and align with accepted clinical standards, especially when a service is complex or unique.

If billing for a non-specific code when a more appropriate code is available, the claim will be rejected. The provider will be requested to resubmit the claim with the correct information.

If the non-specific code is appropriate for the service rendered and approved for medical necessity, default reimbursement will be 35% of the billed amount unless other pricing guidance applies.

This update increases review of certain codes but does not change how you submit claims or participate in reviews.