Highmark to Perform Hospital OPPS Claim Reviews

Highmark will perform Hospital Outpatient Prospective Payment System (OPPS) Based Payment Method claim reviews starting Nov. 1, 2026, consistent with Highmark reimbursement policies and based on the direction below:

When cost outliers are part of a hospital’s contracted  OPPS based payment method, cost outliers will be calculated based on billed charges adjusted by the provider’s CMS OPPS cost-to-charge ratio for all items except:

• Drugs and Biologicals: Costs are calculated in accordance with Reimbursement Policy (RP)-019A: Drugs and Biologicals.*
• Implants: Costs are calculated in accordance with RP-061: Implants and Implant Components.
• Not Separately Reimbursable: Costs are calculated in accordance with RP-040: Facility Routine Supplies and Services and RP-080: Integral or Necessary Services.

Highmark retains the authority to conduct detailed line-item reviews of billed services, aligning with payment policies RP-019A,RP-040, RP-061, and RP-080, and may also perform audit functions such as chargemaster reviews.

The Highmark Hospital OPPS Based Payment Method Provider Training Manual will be updated to reflect this direction and application of Highmark reimbursement policies as described above effective November 1, 2026.  

*To view RP-019A, you must be logged into Availity Essentials^®.