New and Updated Reimbursement Policies – January 2026
Mon, Jan 26, 2026
Highmark regularly issues new or updated reimbursement policies. Keep an eye on the Provider Resource Center (PRC) for announcements regarding upcoming policy changes. As specific policy changes go into effect, the updated policies can be found on the Reimbursement Policies page of the PRC.
Below is a list of recent and upcoming updates to reimbursement policies (RPs):
Recently Updated
Dec. 24, 2025
RP-053 Advanced Gene and Cellular Therapies
New drugs/therapies applicable to this policy were added.
Jan. 1, 2026
RP-006 Multiple Endoscopy Procedures
Code 52443 was added to endo base procedure 52000, code 0991T was added to endo base procedure 52351, and code 43889 was added to endo base procedure 43235.
RP-007 Multiple Procedure Payment Reduction for Certain Diagnostic Imaging Procedures
Codes 70471, 70473, and 1010T were added. Code 75842 was removed.
- wny
- neny
RP-009 Modifiers 25, 59, XE, XP, XS, XU, and FT
A note was added to indicate that exceptions may apply for code 99051 in New York only.
RP-042 Global Surgery and Subsequent Services
Codes 0994T, 0995T, 0988T, 1003T, 1012T, 1013T, and 1015T were added to the global YYY codes sections for Commercial and Medicare Advantage.
- wpa/ nepa
- cpa/ sepa
- wny
- neny
RP-068 Mid-Level Practitioners and Advanced Practice Providers
This policy was updated for Commercial and Medicare Advantage to add direction for the pharmacist specialty, which will be reimbursed at 85% of the fee schedule allowance.
- wv
RP-068 Mid-Level Practitioners and Advanced Practice Providers
This policy was updated for Medicare Advantage to add direction for the pharmacist specialty, which will be reimbursed at 85% of the fee schedule allowance.
- de
RP-068 Mid-Level Practitioners and Advanced Practice Providers
This policy was updated to add direction for the pharmacist specialty, which will be reimbursed at 85% of the fee schedule allowance for Commercial and Medicare Advantage. Direction was also added for the doula specialty, which will be reimbursed at 85% of the fee schedule allowance for Commercial.
NEW: RP-083 Spravato® (esketamine)
This new policy – applicable to Commercial and Medicare Advantage markets – provides direction on the billing of Spravato (esketamine) services.
Jan. 5, 2026
RP-027 Hemodialysis and Peritoneal Dialysis
This policy was made applicable to Medicare Advantage. Codes 99242-99245 and 99252-99255 were removed. Codes 90993, 90999, 99233, 99291, 99292, 99341, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, S9335, and S9339 were added.
- wny
- neny
Jan. 26, 2026
RP-009 Modifiers 25, 59, XE, XP, XS, XU, and FT
An effective date (Jan. 1, 2026) was added to the note that states exceptions may apply for code 99051 in New York only.
Upcoming
Feb. 2, 2026
RP-011 Procedure Codes Not Applicable to Commercial Products
Code G0071 will be removed.
Feb. 23, 2026
RP-041 Services Not Separately Reimbursed
Codes 76376 and 76377 will be added to this policy as not separately reimbursed for Commercial and Medicare Advantage.
NEW: RP-084 Remote Patient Monitoring
The purpose of this new policy, effective Feb. 23, 2026, is to get in front of cost and utilization trends around this growing service. This new policy direction will clarify when and how remote patient monitoring (RPM) should be used and when it will be reimbursed by the plan. It will provide guidelines on RPM usage by providers and reimbursement for RPM-specific Current Procedural Terminology (CPT) codes.
- wpa/ nepa
- cpa/ sepa
- de
- wny
- neny
March 2, 2026
RP-068 Mid-Level Practitioners and Advanced Practice Providers
This policy will be updated to include the certified registered nurse anesthetist (CRNA) specialty, which will be reimbursed at 85% of the fee schedule allowance for Commercial, effective March 2, 2026.
- wpa/ nepa
- cpa/ sepa
- de
- wv
March 30, 2026
RP-004 Modifiers 52 and 53
This policy will be made applicable to Medicare Advantage.
RP-037 Emergency Evaluation and Management Coding Guidelines
This policy will be made applicable to Delaware, Pennsylvania, and West Virginia professional claims, which will be reviewed by Highmark when submitted for emergency department services, effective March 30, 2026. For more information, CLICK HERE. (NOTE: This policy update was previously communicated as having a Feb. 2, 2026, effective date. That effective date has been pushed back to March 30, 2026.)
April 27, 2026
RP-009 Modifiers 25, 59, XE, XP, XS, XU, and FT
The After-Hours Codes section will be removed from this policy, as those codes and direction will be moved to RP-041 Services Not Separately Reimbursed.
RP-033 Anesthesia Services
Direction for physical status modifiers will be removed.
- wny
- neny
RP-037 Emergency Evaluation and Management Coding Guidelines
This policy will be made applicable to New York professional claims, which will be reviewed by Highmark when submitted for emergency department services, effective April 27, 2026. For more information, CLICK HERE. (NOTE: This policy update was previously communicated as having a Feb. 2, 2026, effective date. That effective date has been pushed back to April 27, 2026.)
RP-041 Services Not Separately Reimbursed
Codes 99050, 99051, 99053, 99056, 99058, 99060, 99288, 96041, 99485, 99486, and G2211 will be added. Codes 92921, 92925, 92929, 92934, and 92938 will be removed.
RP-047 Venipuncture and Lab Services
Medicare Advantage direction will be changed.
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