New and Updated Reimbursement Policies – July 2026

Highmark regularly issues new or updated reimbursement policies. Keep an eye on the Communications Hub of 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

July 1, 2026

RP-003 Convenience Kits, Drug and Biological Wastage

The Centers for Medicare and Medicaid Services (CMS) began reimbursing non-BLA (Biologics License Application) skin substitutes as incident-to supplies at a flat national rate, effective Jan. 1, 2026. Highmark has adopted the CMS flat national rate pricing methodology for non-BLA skin substitutes – with the change taking effect July 1, 2026, for Commercial plans and retroactive to Jan. 1, 2026, for Medicare Advantage plans. For more information, CLICK HERE.

July 27, 2026

RP-001 Assistant at Surgery Services

This policy underwent an administrative review. No changes in direction were made.

RP-002 Co-Surgery

This policy underwent an administrative review. No changes in direction were made.

RP-004 Modifiers 52, 53, 54, 55, and 56

This policy was updated to merge direction from RP-005 Modifiers 54, 55, and 56 (see below). The policy name for RP-004 was also changed from “Modifiers 52 and 53” to “Modifiers 52, 53, 54, 55, and 56.”

RP-005 Modifiers 54, 55, and 56

RP-005 was archived, effective July 27, 2026, with policy direction moved to RP-004 Modifiers 52, 53, 54, 55, and 56 (see above).

RP-006 Multiple Endoscopy Procedures

Code 1040T was added to endo base procedure 31622.

RP-007 Multiple Procedure Payment Reduction for Certain Diagnostic Imaging Procedures

Codes 1039T, 1043T, 1036T, 1052T, and 1053T were added.

RP-011 Procedure Codes Not Applicable to Commercial Products

Codes G0574 and G0575 were added.

RP-014 Bilateral and Multiple Surgical Procedures

This policy underwent an administrative review. Policy direction was streamlined.

RP-034 Prolonged Detention or Critical Care

Codes G2211 and 94662 were removed and policy direction was streamlined.

RP-036 Preventable Serious Adverse Events

This policy underwent an administrative review. No changes in direction were made.

RP-042 Global Surgery and Subsequent Services

Codes 1027T, 1037T, 1044T, 1046T, and 1048T were added to the global YYY codes sections for Commercial and Medicare Advantage.

RP-052 Surgical Team

This policy underwent an administrative review. No changes in direction were made.

RP-069 Durable Medical Equipment

This policy was updated with additional modifiers and direction, including direction merged from RP-070 Continuous Rental of Life Sustaining DME (see below). The policy name for RP-069 was also changed from “DME Maintenance, Repair, and Replacement” to “Durable Medical Equipment.”

RP-070 Continuous Rental of Life Sustaining DME

RP-070 was archived, effective July 27, 2026, with policy direction moved to RP-069 Durable Medical Equipment (see above).

Upcoming

Aug. 24, 2026

RP-012 Rigid Immobilization

This policy will be made applicable to Medicare Advantage. Codes 29086, 29130, 29131, 29200, 29240, 29260, 29280, 29440, 29450, 29520, 29530, 29540, 29550, 29580, 29581, and 29584 will be added.

Aug. 31, 2026

RP-064 Government Supplied Vaccines and Antibody Treatments

Special direction for SARS-CoV-2 vaccines and antibody treatments will be removed.

Sept. 1, 2026

RP-046 Telemedicine and Telehealth Services

Effective Sept. 1, 2026, Highmark will update its telemedicine and telehealth policy to align with guidance from the Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA). For more information, CLICK HERE.

Sept. 28, 2026

RP-041 Services Not Separately Reimbursed

Codes 77387, 77417, and 77439 will be added for Commercial and Medicare Advantage. In addition, a list of Status B codes – which has already been applicable for Medicare Advantage – will be added for clarity.

NEW: RP-085 Observation Care

Aligning with the Centers for Medicare and Medicaid Services (CMS), this new policy will provide reimbursement direction for observation services when performed for eight hours or less and separately payable from emergency room billing. This policy direction will be enforced on a post-pay basis.

Oct. 26, 2026

RP-051 Multiple Procedure Payment Reduction for Therapy Services

Effective Oct. 26, 2026, Highmark will no longer allow for the separate reimbursement of code 97124 for providers designated in the following specialties: Chiropractic, Physical Therapy, Occupational Therapy, and Physiatry. To reflect this change, direction for code 97124 will be added to RP-051, applicable to Commercial and Medicare Advantage for all regions. For more information, CLICK HERE.

Nov. 1, 2026

RP-010 Incident To Services

Modifier SA will be required when reporting “incident to” services, effective Nov. 1, 2026. Direction for this requirement will be added to RP-010.