CommercialPrior AuthHigh impact
MSK Codes Being Added to Site of Care Policy on May 1
Highmark·PA, DE, WV, NY · Orthopedics, Pain Management, General Surgery·Provider Bulletin
Effective date
May 1, 2026
We identified it
Mar 25, 2026
Summary
Beginning May 1, 2026, Highmark is adding 113 musculoskeletal (MSK) surgical procedure codes to their site of care clinical review requirements, encouraging these procedures to be performed in ASCs or office-based settings rather than hospital outpatient departments. Authorization management for MSK services is also moving from eviCore to Highmark and must be submitted through Availity Essentials portal.
Action Required
Before May 1, 2026: Billing team must register for Availity Essentials portal if not already using it, as all MSK procedure authorizations must now be submitted to Highmark directly instead of eviCore. Update authorization workflows to submit MSK surgical procedures through Availity for faster processing. Review Medical Policy Z-109 (Commercial) and Z-129 (Medicare Advantage) to understand specific criteria for when hospital outpatient settings may still be used for the 113 new MSK codes.