The New Year will bring updates to Highmark policies and programs, including reimbursement, provider networks, and claims. Consult the list of published articles below for additional details.
Jan. 1, 2026
Highmark will launch a program that outlines site of care clinical review requirements for certain low-risk outpatient surgeries. This initiative aims to improve efficiency by encouraging utilization of freestanding Ambulatory Surgery Centers (ASCs) or office-based settings, where appropriate.
Since this program was initially communicated in Sept. 2025, the two medical policies that outline procedures and site of care clinical review requirements were modified. Medical Policy Z-109 (Commercial)* and Medical Policy Z-129 (Medicare Advantage) now include exclusions that introduce more flexibility.
The following language was added to the policies:
“Site of care clinical review will take into consideration whether:
The treating network participating provider recommends, based on a written clinical justification submitted to Highmark, that the service be provided at a hospital-based outpatient clinic; or
The member requested a particular network participating provider who performs the requested service in a hospital-based outpatient clinic because the member is undergoing a continuing course of treatment with the participating provider or because the member has previously obtained the requested service from the participating provider, and the provider is not credentialed at any free-standing ambulatory surgical center in the service area and is not able to be credentialed within ninety days following the submission of the authorization request to the health care plan.”
You can access the policies for your state using the links below:
| Delaware | Commercial | Medicare Advantage |
| New York | Commercial | Medicare Advantage |
| Pennsylvania | Commercial | Medicare Advantage |
| West Virginia | Commercial | Medicare Advantage |
*No changes have been made to Medical Policy Z-109 (Commercial) for New York.
We are updating select Medicare Advantage networks, effective Jan. 1, 2026. Impacted providers and members will have received letters outlining these changes and what they may mean for them.
Note: These changes do not impact Commercial or Affordable Care Act (ACA) lines of business.
Highmark is making adjustments to our Affordable Care Act (ACA), Commercial, and Medicare Advantage (MA) programs to enhance benefits, improve access to care, and ensure long-term sustainability.
We are launching CopayGo, an innovative alternative health product designed for our Administrative Services Only (ASO) large group accounts. CopayGo simplifies healthcare costs with a national two-tiered network of "Enhanced" and "Standard" providers.
A new prospective risk adjustment program compensation model for all markets and lines of business will be implemented on Jan. 1, 2026. This new model will allow for flexible and easier program participation, recognize higher performance, and increase targeted gap opportunity.
- wny
- neny
Jan. 26, 2026
Highmark is making important changes to how we deliver payments/remittances (835s) and process electronic claims (837s) for our New York providers. These changes are designed to streamline processes and improve efficiency.
Effective Jan. 26, 2026, Highmark is expanding its partnership with ECHO Health to manage payments and remittances for Western and Northeastern New York.
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