All PlansPrior AuthMedium impact
Technical Coding Alignment for Prior Auth Processing of Select MIDs
Highmark·PA, NY, WV, DE · Oncology, Hematology, Rheumatology·Prior Authorization
Effective date
Sep 1, 2026
We identified it
Jul 28, 2026
Summary
Effective September 1, 2026, Highmark is aligning technical coding configurations for prior authorization processing of 20 select medical injectable drugs (MIDs), including new denosumab biosimilars and oncology/specialty drugs. This ensures consistency with previously published prior authorization requirements. While widespread impact is not anticipated, variations may occur based on individual benefit plans and eligibility.
Action Required
By August 31, 2026: Billing team must verify that all 17 affected HCPCS codes (Q5157, Q5158, Q5159, J9248, J9021, J9347, J9272, J9011, J9282, J9061, J9326, Q5122, J9227, J1448, J0224, Q5118, J9038) are configured in the billing system to require prior authorization through Availity Essentials for Highmark plans. Confirm that system rules align with the technical coding configuration by September 1, 2026. Verify member eligibility and benefits through Availity's Patient Registration feature before claim submission. Reference the most up-to-date Highmark Medical Policies via the Provider Resource Center (PRC) to confirm coverage criteria for each injectable. Communicate any changes to clinical staff. Claims submitted without proper prior authorization may be denied.