CommercialPrior AuthHigh impact
Upcoming Site of Care Program Impacts Certain Outpatient Surgeries
Highmark·PA, DE, NY, WV · General Surgery, Orthopedics, ENT (Ear, Nose & Throat) +4 more·Provider Bulletin
Effective date
Jan 1, 2026
We identified it
Sep 29, 2025
Summary
Starting January 1, 2026, Highmark will require prior authorization for certain low-risk outpatient surgeries performed in hospital outpatient departments, encouraging use of ambulatory surgery centers or office-based settings instead. Two new medical policies (Z-109 for Commercial, Z-129 for Medicare Advantage) will define covered procedures and review requirements.
Action Required
By December 31, 2025: Billing team must prepare for new prior authorization requirements for outpatient surgeries in hospital settings. Review new Medical Policies Z-109 (Commercial) and Z-129 (Medicare Advantage) when published on October 1, 2025. Update billing workflows to submit authorization requests through Availity Essentials for applicable procedures. Train staff on site of care documentation requirements including patient complexity, geographic limitations, and clinical judgment justifications for hospital outpatient settings.