Upcoming Site of Care Program Impacts Certain Outpatient Surgeries

Effective 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.

Evidence has shown that for select procedures and patients, ASC and office-based settings are more convenient and represent better value for patients.

While Highmark strongly encourages the utilization of ASCs or office-based settings for eligible procedures, we recognize that certain clinical situations may necessitate a hospital outpatient setting. Providers may perform the procedures in a hospital outpatient department setting under specific criteria, including:

• Patient complexity and comorbid conditions.
• Geographic limitations (e.g., access to ASCs in rural areas).
• Clinical judgment and other factors.

Site of care clinical review requirements will apply to Highmark fully insured Commercial, Affordable Care Act (ACA), and Medicare Advantage (MA) members. Please confirm member benefits to ensure in-network site of care requirements apply.

Medical Policy Updates

Two new medical policies — Medical Policy Z-109 (Commercial) and Medical Policy Z-129 (Medicare Advantage) — outline the procedures and site of care clinical review requirements. Site of care clinical review will be applicable to a wide variety of surgical procedures, as defined in the medical policies. Highmark regularly reviews its policies to ensure alignment with nationally recognized clinical evidence, safety, and compliance guidelines. As such, the procedures covered under our site of care policies are subject to change and may vary across lines of business.

The policies will be published on Highmark’s Medical Policy Search sites on Oct. 1, 2025. You can access the search sites here on the Provider Resource Center (PRC). Click on Policies & Programs > Medical Policies and then the search sites for your state:

Submitting Authorization Requests

Providers can submit authorization requests for site of care clinical review through Availity Essentials^®, our provider portal. Submitting electronically leads to faster reviews and response times.

Highmark participating providers have the right to request a real-time clinical peer to
peer discussion as part of the authorization process for commercial members.

Additional information on authorization submission can be found under Claims & Authorization on the Provider Resource Center or in the Highmark Provider Manual: Chapter 5, Unit 2 (Authorizations).

We are confident that this collaborative approach will enhance the quality of care while ensuring affordability and access for all our members. We appreciate your cooperation and partnership in this important initiative.