Update: Low Acuity Non-Emergent Professional Claim Review

Highmark will begin reviewing Emergency Department professional claims submitted with procedure codes 99284 and 99285, which indicate moderate and high complexity levels. This will be effective for Delaware (DE), Pennsylvania (PA), and West Virginia (WV) on March 30, 2026, and for New York (NY) on April 27, 2026.

These reviews are designed to determine the appropriate and fair level of professional reimbursement for emergency department services based on Centers for Medicare and Medicaid Services (CMS) criteria and Mercer’s Low Acuity Non-Emergent (LANE) analysis.

Low-Acuity Visits

If the presenting diagnosis is of low-level complexity or is deemed as a low acuity, non-emergent visit, the service will be automatically downcoded from a level 4 (99284) or level 5 (99285) to a level 3 (99283). This aligns with CMS’ definition of that code level where the presenting problem requires a low level of medical decision making.

For more information about this program, refer to Reimbursement Policy (RP)-037: Emergency Evaluation and Management Coding Guidelines. Use the link for your region below to preview the version of the policy that will be effective on the dates noted above.

• DE, PA, and WV
• NY

Determining How the Claim Was Changed

If the review determines that the claim warrants the level of care at which it was billed, the claim will not be changed.

If the review — conducted using Highmark’s RP-037 — determines the claim warrants a different level of care based on the presenting diagnosis, Highmark will deactivate the original line and add a new line with the correct procedure code and reimburse accordingly.

The code originally submitted on the claim and the code Highmark adds to the claim will be stored in Highmark systems for CMS audits. The Explanation of Payment (EOP) will show both the submitted procedure code as well as the adjusted procedure code that Highmark applies to the claim.

Questions About Claims or How to Appeal the Updated CPT Code

The notification of payment for the newly updated CPT code will come in the form of an EOP. There will be no denial letters. If there are questions regarding the updated coding of the claim, contact Highmark via Message this Payer in Availity Essentials.

Providers who do not agree with Highmark’s updated CPT Code can request an appeal.

Please submit the appeal request and medical records that substantiate the appeal to:

Attention: Payment Integrity
Highmark Inc.
PO Box 890120
Camp Hill, PA 17089