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Highmark to Perform Hospital OPPS Claim Reviews
Act
by Oct 1, 2026
Effective date
Nov 1, 2026
Identified
Jul 28, 2026
Summary
Starting November 1, 2026, Highmark will implement Hospital OPPS claim reviews using cost-to-charge ratios adjusted by CMS OPPS methodology, with specific exclusions for drugs/biologicals, implants, and non-separately reimbursable items governed by specific reimbursement policies (RP-019A, RP-040, RP-061, RP-080). Highmark retains authority to conduct detailed line-item reviews and chargemaster audits. The Hospital OPPS Based Payment Method Provider Training Manual will be updated to reflect these changes.
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What to do
by Oct 1, 2026 · 4 steps
01Billing team must review and understand Highmark's reimbursement policies RP-019A (Drugs and Biologicals), RP-040 (Facility Routine Supplies and Services), RP-061 (Implants and Implant Components), and RP-080 (Integral or Necessary Services) to prepare for OPPS claim review methodology changes.
02Ensure billing staff can distinguish between items subject to cost-to-charge ratio calculations versus those subject to policy-specific costing.
03Update internal documentation and billing procedures to reflect the new OPPS review framework.
04By November 1, 2026: All hospital outpatient claims must be submitted with accurate chargemaster data and cost allocation supporting the CMS OPPS cost-to-charge ratio methodology.
If missed: Failure to comply may result in claim denials, audits, or payment adjustments for cost outlier calculations.
Original notice
Highmark to Perform Hospital OPPS Claim Reviews
providers.highmark.com · Always check the source before changing claims.