Medicare AdvantageReimbursementHigh impact
Reimbursement Policy Changes for Billing of Skin Substitutes
Highmark·DE, PA, WV, NY · Dermatology, Wound Care, General Surgery +4 more·Provider Bulletin
Effective date
Jan 1, 2026
We identified it
Jul 4, 2026
Summary
Highmark is updating reimbursement methodology for skin substitutes, effective immediately for modifier reporting and staggered implementation of flat national rate pricing (Jan 1, 2026 for Medicare Advantage, July 1, 2026 for Commercial plans). Providers must now append modifiers JW and/or JZ to skin substitute claim lines for tracking purposes. BLA skin substitutes will continue using ASP methodology for both plan types.
Action Required
IMMEDIATE (modifier requirement): Billing team must configure billing software to require modifiers JW (Drug/Biological amount discarded/not administered) and/or JZ (Zero drug amount discarded/not administered) on all skin substitute claim lines. Update claim submission workflows and provider education materials to reflect mandatory modifier usage for tracking purposes. Claims submitted without appropriate modifiers may be flagged or rejected. BY JANUARY 1, 2026 (Medicare Advantage): Update billing system to apply flat national rate pricing (per CMS methodology) instead of current pricing for all non-BLA skin substitutes in Medicare Advantage plans. Communicate reimbursement rate changes to providers and update fee schedules in billing software. BY JULY 1, 2026 (Commercial): Update billing system to apply flat national rate pricing for non-BLA skin substitutes in Commercial plans. Continue using ASP methodology for BLA skin substitutes across all plan types. Coordinate with compliance team to monitor modifier usage trends for internal auditing and utilization analysis.